Every finding on record at Pinnacle Specialty Care

Based on electronic health record (EHR), facility records, facility policies and staff interviews the facility failed to timely report an allegation of abuse for 1 of 2 residents (Resident #33) reviewed. The facility reported a census of 92 residents. Findings include:Resident #33's Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented Resident #33 had no hallucinations (seeing things not there) or delusions (false beliefs). The MDS identified Resident #33 as occasionally incontinent of urine. The MDS documented Resident #33 had a recent surgery and required surgical wound care. The MDS included diagnoses of heart failure (weak heart), diabetes mellitus (high blood sugar), and hip fracture (broken hip). The Care Plan Report initiated on 4/15/26 identified Resident #33 had skin impairment to a surgical hip and a blister to the top of the left foot. The Care Plan included the following Interventions:4/15/26: Staff to educate Resident #33, family, and caregivers of causative factors and measures to prevent skin injury.4/16/26: Staff to monitor for and document the location, size, and treatment of skin injury.4/30/26: Staff to apply Tubi grips (elastic bandages) from knees to toes in the morning and off in the afternoon. A Grievance/Concern Investigation form dated 4/29/26 signed by a Resident #33's Representative alleged negligent care. The section labeled Action and Follow-up indicated the Administrator discussed Resident #33's care with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) - all care was performed appropriately and per the doctor's orders. The Administrator signed 4/29/26. A Grievance/Concern Investigation form dated 4/30/26 alleged the facility didn't follow the wound orders and Resident #33 had wraps left on all night that were to be taken off. The wraps were too tight and cut off blood circulation which left bruises and blisters. The Traveling Director of Nursing Services (DON) documented the provider saw Resident #33 on 4/28/26 and gave new orders. The provider saw Resident #33 on 4/30/26 and explained to Resident #33's daughter, her feet appeared better than prior. A Social Service Note on 4/30/26 at 11:14 AM documented Resident #33's daughter came in today to talk with the Social Worker about issues with her mom's foot. The daughter felt very concerned with Resident #33's feet and felt scared to take her home. An Order Administration Note on 4/30/26 at 6:02 PM documented Resident #33 discharged at 3:40 PM. Review of the Self Reports provided by the facility documented an incident dated 4/15/26 filed 5/28/26 with the incident type listed as other. On 5/28/26 at 3:20 PM, the Area Administrator verbalized when they reviewed the Grievance/Concern Investigation Form, she realized they should have submitted a facility self-report. The Area Administrator acknowledged they submitted the facility self-report on 5/28/25 for an allegation of abuse that occurred in April 2026. The Area Administrator acknowledged the facility didn't submit the self-report timely. The Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation policy revised April 2021 directed the following:Reporting Allegations to the Administrator and AuthoritiesIf resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:i. The state licensing/certification agency responsible for surveying/licensing the facility;ii. The local/state ombudsman;iii. The resident's representative;iv. Adult protective services (where state law provides jurisdiction in long-term care);v. Law enforcement officials;vi. The resident's attending physician; andvii. The facility medical director. Reporting Results of InvestigationsThe administrator, or his/her designee, provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation.

Based on electronic health record (EHR), facility records, personnel file and staff interview the facility failed to develop and implement a comprehensive Care Plan for 1 of 3 residents (Resident #22) reviewed. The facility reported a census of 92 residents. Findings include:Resident #22's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of anxiety disorder (excessive worry), type II diabetes mellitus (high blood sugar), and osteoarthritis (chronic joint pain). Resident #22 received scheduled pain medications and occasionally experienced pain in the five-day look-back period. The Care Plan Report initiated on 7/25/24 identified a focus area for activities of daily living (everyday tasks) that directed staff to follow these interventions:Two-assist with bed mobility.Toileting: Two-assist with a mechanical lift when toileting.Provide care in pairs initiated 5/14/26. The Documentation Survey Report V2 for April 2026 revealed Staff B, Certified Nursing Assistant (CNA), provided bowel and bladder elimination for incontinence (loss of bladder or bowel control) care on 4/26/26 at 12:49 AM and also on 4/27/26 at 2:42 AM on the overnight shifts. On 5/27/26 at 3:55 PM, Resident #22 verbalized a CNA changed her brief and verbalized she felt a knuckle in her back and reported it to Staff A, the Interim Administrator. Resident #22 couldn't recall the date, but verbalized it occurred on the overnight shift. Resident #22 reported she's very sensitive to touch. On 5/8/26 at 9:32 AM, Staff B reported she's familiar with Resident #22. Staff B reported Resident #22 required the assistance of 2 staff members. Staff B recalled providing care for Resident #22 on an overnight shift from 10:00 PM to 6:00 AM on Sunday night, 4/26/26. Staff B verbalized for bed mobility; Resident #22 only required the assistance of one staff member. Staff B revealed she's the only CNA scheduled on the unit. Staff B admitted they had no other staff members in the room when she changed Resident #22's incontinent brief. Staff B reported she entered the room and asked Resident #22 if she needed changed. Staff B verbalized Resident #22's a heavier lady and placed an open hand on Resident #22's shoulder and an open hand on Resident #22's waist/back to assist Resident #22 to roll to one side to be changed. Staff B reported at no time would her knuckles touch a resident's back since staff use open hands with fingers extended and the palm side of the hand touching the resident. On 6/2/26 at 1:15 PM, Staff C, Licensed Practical Nurse (LPN), verbalized she's familiar with Resident #22. Staff C reported that for a check and change of an incontinent brief for Resident #22, 2 staff members must assist with care in pairs. On 6/3/26 at 12:20 PM, the Traveling Director of Nursing (DON) acknowledged Resident #22 required the assistance of 2 staff members for bed mobility. The Traveling DON expected care provided per the plan of care for each resident. The Job Description for the position of Certified Nursing Assistant dated April 2021 within Staff B's Personnel File documented a hire date of 4/23/21. Staff B electronically signed the Job Description on 4/2/21 at 4:29 PM. The form instructed the employee to fulfill the following essential functions:Review care plans and perform nursing care as outlined.Assist residents with activities of daily living as documented in the resident's care plan. Staff B's Orientation Checklist: Nursing Assistant dated February 2023 signed by Staff B 2/11/23 verifying all of the above had been reviewed. The form documented Staff B received training on Care Plans and Care Guides.

Based on observation, electronic health record (EHR), facility policy review, resident and staff interviews, the facility failed to consistently respond to activated call lights within a reasonable amount of time. Residents reported having to wait up to 2 hours for a call light to be answered. Observations revealed a response time greater than 15 minutes for 2 of 2 residents observed (Residents #12 and #35). The facility reported a census of 92.Findings Include:1. Resident #35's Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS listed Resident #35 as dependent (helper does all effort) for toileting hygiene. Resident #35 required partial/moderate assistance (helper does less than half effort) for toilet transfers. The MDS included diagnoses of diabetes mellitus (high blood sugar), Alzheimer's disease (progressive memory loss), and post-traumatic stress disorder (PTSD) (trauma-induced anxiety). The Care Plan Focus initiated 1/13/26 related to Resident #35's activities of daily living (ADLs) (everyday tasks). The Interventions directed staff that ambulation (walking) required an assist of 1, toileting required an assist of 1, and transfers required an assist of 1. The Care Plan Focus initiated 4/18/26 indicated Resident #35 had a risk for falls. An intervention initiated on 4/18/26 directed staff to encourage Resident #35 to use the call light for assistance. On 6/1/26 at 2:24 PM, Staff D, Certified Nursing Assistant (CNA), stated staff are alerted to activated call lights through the monitor at the nurse's station. Staff D reported they should respond to a call light right away. Staff D revealed Resident #35 voiced concerns about the length of time it took staff to respond to call lights. On 6/1/26 at 2:33 PM, observed Resident #35 sitting in his wheelchair outside his room. Resident #35 stated he waited for someone to take him to the bathroom. He stated he had to go now. On 6/1/26 at 2:44 PM, the Call Light monitor at the nurse's station revealed a bed E-call (electronic call light) for room [ROOM NUMBER] Bed 2 with an age of 44 minutes and 16 seconds at the eighth resound. 2. Resident #12's MDS dated [DATE] included a BIMS score of 15, indicating intact cognition. Resident #12 required partial/moderate assistance for toileting hygiene and toilet transfers. The Care Plan Focus revised 9/25/24 indicated Resident #12 had a risk for falls related to weakness, seizures, and a fall on 6/29/23 that resulted in a left hip fracture. The Intervention revised 9/25/24 directed staff to educate Resident #12 to use her call light for assistance. On 5/28/26 at 1:10 PM, the Call Light monitor at the nurse's station revealed a bath E-call for room [ROOM NUMBER] with an age of 15 minutes and 58 seconds at the third resound. On 5/27/26 at 2:58 PM, Resident #12 reported sometimes it took a long time for staff to respond to her call light. Resident #12 explained about 2 to 3 weeks ago she went to the bathroom and it took 2 hours for staff to respond. Resident #12 reported the bathroom door stayed open and she could see the clock on the wall from her bathroom. Resident #12 stated she had episodes of incontinence (loss of bladder control) since she cannot hold her urine like she did when she lived as a younger woman. On 6/2/26 at 1:15 PM, Staff F, Licensed Practical Nurse (LPN), stated an appropriate response time to an activated call light equaled 15 minutes. On 6/3/26 at 12:20 PM, the Traveling Director of Nursing (DON) stated the facility policy didn't state a targeted time for answering a call light. She acknowledged regulations state 15 minutes as an appropriate response time. On 6/4/26 at 11:29 AM, Staff E, Maintenance, reported if a call light does not operate properly, staff report the issue to him and enter a maintenance ticket in the work order system. Staff E acknowledged he didn't have any recent work orders for the call lights in rooms 302 or 516. The facility's Call Light policy guidelines revealed the age of the alarm displays in hours, minutes, and seconds on the display unit. Once an alarm hits a 5-minute interval, it turns yellow and re-alarms. Alarms resound every 5 minutes for an hour. The Answering the Call Light Policy reviewed March 2021 instructed the purpose of the procedure is to ensure timely response to the residents' requests and needs. The policy directed staff to identify themselves and politely respond to the resident by name. If the resident needs assistance, staff must indicate the approximate time it will take to respond. If the resident's request required another staff member, staff must notify that individual. If staff feel uncertain whether a request can be fulfilled, or if they cannot fulfill the request, they must ask the nurse supervisor for assistance. If assistance is needed when entering the room, staff must summon help by using the call signal. The policy lacked a definition for what constitutes a timely response to a resident's needs.

Based on observation, electronic health record (EHR), Medication Administration Record (MAR), facility records, facility policy review, resident and staff interviews, the facility failed ensure medication administration was performed in accordance with physician orders and failed to maintain accurate medical record documentation for 2 of 8 residents (Resident #16 and #19) reviewed. The facility reported a census of 92 residents. Findings Include:1. Resident #19's Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented Resident #19 had no hallucinations (seeing things that aren't there) or delusions (false beliefs). The MDS documented Resident #19 was dependent on a helper for all effort to roll left and right and for chair/bed-to-chair transfers. The MDS documented Resident #19 received scheduled and as-needed pain medications. The MDS identified Resident #19 experienced pain almost constantly. The MDS included diagnoses of multiple sclerosis (MS - a chronic autoimmune disease that affects the central nervous system), quadriplegia (paralysis of all four limbs), and anxiety disorder. The Care Plan Focus revised 2/5/26 indicated Resident #19 used opioid medications as needed (PRN). The Intervention dated 3/9/21 directed to administer opioid medication as physician ordered and monitor for side effects. A Physician Order dated 4/29/26 at 12:53 PM directed staff to give Resident #19 morphine sulfate extended release (ER) 30 milligrams (mg) by mouth every 8 hours for pain. The order noted that morphine sulfate is an opioid analgesic (pain reliever) and a controlled drug. A Physician Order dated 5/13/26 at 2:12 PM directed staff to give Resident #19 hydrocodone-acetaminophen 5-325 mg by mouth every 12 hours as needed for pain, not to exceed 3,000 mg daily. The order noted that hydrocodone-acetaminophen is an opioid analgesic and a controlled drug. Resident #19's Individual Narcotic Record for morphine ER 30 mg for May 2026 revealed Staff H administered 1 tablet on 5/19/26 at 4:20 PM and another tablet on 5/19/26 at 8:00 PM. Resident #19's May 2026 Medication Administration Record (MAR) identified Staff H, Licensed Practical Nurse (LPN), morphine sulfate ER 30 mg at 4:00 PM with a reported pain level of 10 (indicating severe pain). Staff H marked completed that the advanced registered nurse practitioner (ARNP) on call should receive notification of any change in condition. The MAR lacked documentation of Resident #19 receiving a dose of morphine sulfate ER 30 mg at 8:00 PM on 5/19/26. The Weights and Vitals report printed 5/28/26 related to pulses on 5/19/26 listed the following:4:32 PM: 94 (a typical persons is expected between 80-100) with an unable to determine pulse type (a typical persons is expected as a regular rhythm and rate).11:32 PM: 66 with an unable to determine pulse type. The Weights and Vitals Report printed 5/28/26 related to blood pressures on 5/19/26, listed the following:4:32 PM - 126/78 (a typical person's is expect around 120/80).11:32 PM - 90/60 The Weights and Vital Report printed 5/28/26 related to oxygen levels on 5/19/26, listed the following:4:32 PM - 97% on room air (expected greater than 90% on room air).11:32 PM - 95% on 6 Liters (L) of oxygen A Physician Order documented in a Nurses Note on 5/19/26 at 10:12 PM directed staff the following:Discontinue Wegovy (diabetic medication also used to treat excessive weight)Start senna+ (medication used to treat/prevent constipation)1 tablet dailyGive hydrocodone with bathing and changing. The Nurses Note dated 5/20/26 at 12:08 AM identified Resident #19 received morphine 30 mg ER at 4:20 PM and 8:00 PM. Staff I, LPN, discovered the extra dose during the narcotic count on 5/19/26 at 10:40 PM. Vital signs taken at the time showed a BP of 90/50, a pulse of 66, a T of 97, and O2 sats of 85 percent on 4 liters of oxygen. The note described Resident #19 as alert and oriented times four. Staff contacted the ARNP, who gave and order to send Resident #19 to the emergency room to monitor the effects of the morphine. The Encounter note dated 5/21/26 documented a post-emergency room encounter for Resident #19. The note stated they saw Resident #19 in her room lying in bed, which represented her baseline and preferred position. She reported ongoing chronic pain, and staff discussed they placed a referral to the pain clinic and was currently being arranged. The note recorded on 5/20/26, Resident #19 received morphine ER 30 mg at 4:20 PM and again at 8:00 PM, and the medication variance was discovered during the narcotic count at 10:40 PM. Vital signs obtained were unremarkable except for an O2 saturation at 85 percent on 4 liters of oxygen. The note described Resident #19 as alert and oriented times four at that time. The facility transferred Resident #19 to the emergency room (ER) for evaluation. While at the ER, they monitored Resident #19 and gave her 1 L of normal saline, then returned her to the facility with no new orders. The clinical record progress notes lacked documentation of an attempt of non-pharmacological interventions for pain on 5/19/26. In addition, the progress notes lacked an Orders-Administration Note for the morphine 30 mg provided on 5/19/26 at 8:00 PM and lacked monitoring for side effects after the 8:00 PM administration. On 5/28/26 at 10:46 AM, Resident #19 stated that a new nurse accidentally gave her an overdose of medication. Resident #19 reported she takes morphine 3 times per day at 8:00 AM, 4:00 PM, and midnight. Resident #19 stated she received the 4:00 PM pill, and then the nurse gave her another morphine at 8:00 PM. On 6/2/26 at 1:34 PM, Staff I stated on 5/19/26, he identified a narcotic count discrepancy involving morphine 30 mg ER during the end-of-shift count with Staff H. An investigation confirmed Resident #19 received a cumulative dose of 60 mg of morphine within a four-hour window due to doses administered at 4:20 PM and 8:00 PM. Following the error, Resident #19's oxygen saturation levels dropped into the 70s. Staff implemented immediate emergency procedures, including vital sign monitoring, provider notification, and transferring Resident #19 to the emergency department. Staff I stayed with Resident #19 and monitored her until the ambulance arrived. Staff H came to take vitals, and Staff J came and informed them they had to send Resident #19 to the emergency room. Staff I documented the discrepancy in the narcotic count book and his personal notes, but he did not chart the incident in the MAR. He stated Staff J was responsible for completing the official incident report, notifying the provider, and communicating with management. On 6/3/26 at 2:15 PM, Staff H confirmed she administered morphine sulfate ER 30 mg to Resident #19 at 4:20 PM and again at 8:00 PM. Staff H acknowledged the 8:00 PM administration reflected a medication error because Resident #19 had a physician order for as-needed hydrocodone-acetaminophen, not morphine sulfate. The error was not recorded in Resident #19's MAR, and Staff H failed to chart the incorrect medication administration or the omission of the ordered as-needed medication. Staff H stated she documented the error on personal report notes and submitted them to Staff A, the Interim Administrator, instead of using the facility's electronic health record (HER) as policy required. Staff H reported feeling distracted and overwhelmed during her shift and stated she lacked the necessary orientation and support to safely manage high-acuity residents like Resident #19 independently. She noted the error was discovered during the end-of-shift narcotic count, and Resident #19 was subsequently transferred to the emergency department. On 6/3/26 at 11:59 AM, Staff J stated she acted as the training nurse for the 2:00 PM to 10:00 PM shift and confirmed a narcotic count discrepancy for morphine 30 mg ER regarding Resident #19 on 5/19/26. Staff J confirmed her trainee, Staff H, incorrectly administered morphine 30 mg ER instead of the ordered as-needed hydrocodone. Staff J noted the trainee failed to record the medication administration on Resident #19's MAR and used personal notes instead. Upon discovering the discrepancy, Staff J initiated emergency procedures, including notifying the physician and family, and the oncoming nurse monitored vitals. Staff J stated she didn't observe Resident #19 between the 8:00 PM administration and the later discovery of the medication error. The Hospital Emergency Department record showed Resident #19 arrived via ambulance on 5/20/26 at 12:21 AM for an emergency admission under emergency medicine services. The admit time was 12:22 AM, and the discharge time was 3:36 AM. The final diagnoses listed accidental poisoning by other opioids, multiple sclerosis, and a personal history of nicotine dependence. The reason for the visit recorded a drug overdose after accidentally receiving an extra dose of morphine at the facility. The record noted Resident #19 takes morphine 30 mg by mouth every 8 hours and received doses at 4:00 PM and 8:00 PM, but she had no symptoms upon arrival. The visit diagnoses included initial encounter for accidental overdose, initial encounter for accidental codeine poisoning, brain stem multiple sclerosis, and a history of tobacco use. The Emergency department staff administered a 1 L bolus of 0.9 percent sodium chloride intravenously starting at 12:57 AM, which finished infusing at 2:15 AM. The physician's differential diagnosis and rationale listed an accidental overdose, noting the patient didn't appear toxic, dehydrated, or septic, was hemodynamically stable, had unremarkable lab and vital signs, and stayed under observation for over 8 hours without issue. The physician counseled Resident #19 on the plan, and she expressed clear understanding. The discharge plan noted the hospital staff contacted poison control, who recommended monitoring for central nervous system and respiratory depression, noting no specific observation window was needed because the dose was within a safe range for her weight. Poison control directed that if respiratory depression occurred, staff should give Narcan and observe for 4 to 6 hours afterward. The facility provider received notification. Staff H's LPN Charge Nurse Job Description revised April 2018 signed 5/12/26 by Staff H. Staff H's Personnel File documented a hire date of 3/3/26. Essential functions required the employee to follow established standards of nursing practices, implement facility policies and procedures, and assume responsibility for unit compliance with rules, regulations, and standards of practice. Staff had to ensure residents received needed nursing care and services according to the plan of care and physician instructions, document care and resident responses, and provide a detailed shift report to oncoming nurses. Staff had to conduct daily resident rounds, report problems, and initiate corrective action. Functions required staff to administer and document medications and treatments per physician orders, accurately record all care, and administer or approve as-needed medications. Staff had to promptly report changes in condition to the physician, DON, and responsible party, monitor medication administration according to regulations, and notify the physician of medication errors or changes in condition. The Personnel File lacked documentation that Staff H received orientation for her specific position. A Suspension Pending Investigation Form dated 5/21/26 for Staff H documented the facility suspended Staff H for a medication administration error while an investigation was pending. The outcome of the suspension noted the ADON educated Staff H on medication administration and completed a return demonstration check. Staff H signed the form on 5/21/26. A Disciplinary Action Form dated 5/20/26 for Staff H recorded no prior coaching or disciplines and listed the infraction type as performance/conduct, resulting in a final warning. The description of the infraction noted that the LPN administered a pain narcotic that was not scheduled to be provided. The nurse received training on the rights of medication but didn't follow those guidelines because she didn't read the MAR. The resident received a second dose approximately four hours before the ordered time, staff completed an assessment and vital signs, and the provider and family received notification. Resident #19 was sent to the emergency room for observation, no injuries or harm occurred, and she returned to the facility approximately four hours later. Staff H acknowledged the form via a phone call on 5/27/26 at 10:30 AM. 2. Resident #16's MDS assessment dated [DATE] included a BIMS score of 15, indicating intact cognition. The MDS listed diagnoses of cerebral palsy (a neurological disorder affecting movement), seizure disorder, and memory/recall ability problems. The MDS documented Resident #16 received antipsychotic, antidepressant, and hypoglycemic (blood sugar lowering) medications. A Grievance/Concern Investigation Form dated 5/11/26 showed Resident #16 reported on 5/8/26, staff didn't give her midday or 4:00 PM medications. The form documented the medications were popped out of the packaging, but the MAR was marked off as given. Management sent an email to the staffing agency requesting a statement from the nurse, Staff G, who worked and documented the medications as given. The Traveling DON signed the form on 5/11/26. The form recorded the facility received an email response from Staff G on 5/13/26 at 1:40 PM. The email stated on Friday, 5/8/26, she popped the midday medications but Resident #16 wasn't in her room or the dining room. Staff G asked a CNA about Resident #16's location, and the CNA stated Resident #16 was out of the facility with family. Staff G disposed of the medications when Resident #16 didn't return, and on 5/14/26, Staff G came to the facility and fixed the documentation. Resident #16's May 2026 MAR showed on 5/8/26, Staff G documented for the midday and PM administration, they administered the lurasidone HCL 40 mg and artificial tears ophthalmic solution, and marked gabapentin 600 mg with a code 9 directing staff to see progress notes. The clinical record progress notes lacked documentation regarding medication errors occurring on 5/8/26 or notification to the physician for the missed medications. A Release of Responsibility for Leave of Absence record for Resident #16 revealed Resident #16 hadn't signed out of the facility on 5/8/26. On 6/1/26 at 10:15 AM, Resident #16 stated there was one day she didn't receive her medications as ordered. Resident #16 reported she didn't remember the exact date but didn't receive her midday and afternoon medications. Resident #16 confirmed she didn't leave the facility that day. On 6/3/26 at 8:04 AM, Staff G stated she worked the first shift from 6:00 AM to 2:00 PM on 5/8/26. Staff G confirmed she had medications for Resident #16 ready, but they weren't in their room and she couldn't find them. Staff G stated a CNA told her Resident #16 had left the building. She confirmed she returned to the facility later to correct her documentation for 5/8/26. On 6/3/26 at 12:20 PM, the Traveling DON stated the expectation is that medications get administered as ordered. She revealed she didn't know about Resident #16's error until a few days after it occurred, but staff notified the physician once the facility became aware. She confirmed Resident #16 didn't sign out to leave the facility on 5/8/26, and stated the nurse should've notified the physician and documented that the resident was unavailable. She acknowledged Resident #16's MAR didn't accurately reflect midday and afternoon medication administration for the medications the resident didn't receive on 5/8/26. The Traveling DON also confirmed a discrepancy occurred with medication administration for Resident #19 on 5/19/26, noting Resident #19 received an additional 30 mg dose of morphine sulfate extended release instead of an ordered as-needed dose of hydrocodone. On 6/4/26 at 10:15 AM, the Traveling DON revealed they hadn't located an orientation checklist for Staff H, but she provided a list of Staff H's training dates. Training on the 200 and 300 halls occurred from 2:00 PM to 10:00 PM on 3/22/26, 3/28/26, 3/29/26, 4/4/26, 4/11/26, 4/12/26, 4/18/26, 4/25/26, 4/26/26, and 5/3/26. Training on the 400 hall from 2:00 PM to 10:00 PM occurred on 5/10/26, 5/12/26, and 5/19/26. Staff H's Personnel File lacked documentation of what she had been trained to do. The Administering Medications policy revised April 2019 instructed that medications are administered in a safe and timely manner, and as prescribed. The policy directed that medications are administered in accordance with prescriber orders, including required timeframes, and that administration times are determined by resident need and benefit, not staff convenience. The policy directed that medication errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes or additional training needs. Medications must be administered within one hour of their prescribed time unless otherwise specified. If a dosage is believed to be inappropriate or excessive, or if a medication is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, attending physician, or medical director. The individual administering medications must verify the resident's identity before giving medications by checking the identification band, checking the photograph attached to the medical record, or verifying identity with other personnel. The individual must check the label 3 times to verify the right resident, right medication, right dosage, right time, and right method of administration. Allergies and vital signs must be verified prior to administration if necessary. If a drug is withheld, refused, or given at an alternate time, the individual must initial and circle the MAR space. The individual initials the MAR after giving each medication and before administering the next ones, and records the date, time, dosage, route, injection site, complaints or symptoms, results achieved, and their signature and title. The Adverse Consequences and Medication Errors policy revised April 2014 instructed the interdisciplinary team evaluates medication usage to prevent and detect adverse consequences and medication-related problems, and reports adverse consequences to the attending physician, pharmacist, and federal agencies as appropriate. The policy directed residents receiving any medication with a potential for an adverse consequence are monitored. An adverse consequence was defined as an unpleasant symptom or event due to a medication, such as an impairment or decline in a mental or physical condition, including adverse reactions, side effects, or interactions. An adverse drug reaction was defined as a secondary, usually undesirable effect of a drug that is noxious and unintended. Staff must minimize consequences by following clinical guidelines and manufacturer specifications. A medication error was defined as preparation or administration not in accordance with physician orders, manufacturer specifications, or accepted standards, and included omissions, unauthorized drugs, wrong doses, wrong routes, wrong forms, wrong drugs, and wrong times. In the event of a significant error-defined as requiring discontinuation or dose modification, requiring or extending hospitalization, resulting in disability, requiring prescription treatment, resulting in cognitive deterioration, or being life-threatening or fatal-immediate action is taken to protect resident safety, and the attending physician is notified promptly and the resident is monitored for 24 to 72 hours.

Based on document review, staff interviews, and facility policy review the facility failed to demonstrate good faith attempts to correct quality deficiencies based on issues identified with repeat deficiencies during the current survey process in 1 area and corrections that remained incomplete in a reasonable time frame. The facility reported a census of 92 residents.Findings include:Review of the Federal Centers for Medicare and Medicaid Services (CMS) form 2567 for the survey results with correction dates of 11/29/25 indicated the facility had received deficiency F725 related to insufficient nursing staff. On 6/9/26 at 11:47 AM, the Assistant Director of Nursing (ADON) reported the facility is continuing to monitor call lights with audits. The ADON further revealed the facility provided education to staff on the spot when they observed staff sitting at the nurse's station with active call lights present. The Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership policy revised March 2020 directed: The responsibilities of the QAPI Committee are to:Collect and analyze performance indicator data and other information;Identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services;Identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process;Utilize root cause analysis to help identify where identified problems point to underlying systematic problems;Help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care;

Based on record review, staff and physician interviews, and policy review the facility failed to ensure stock over-the-counter (OTC) medications were on hand for administration. This failure resulted in medications such as Miralax, Lidocaine patches, Sennaside, and Acetaminophen (APAP) being unavailable for multiple days.The facility reported a census of 93 residents.Findings include: 1. Resident #7's March 2026 Medication Administration Record (MAR) revealed he did not receive Poly-Iron 150 Oral Capsule (medicine used to treat an iron deficiency) 150 milligrams (mg) on 3/12, 3/14, 3/15, 3/16, 3/17, 3/21, 3/22, 3/23, 3/24, and 3/25.Staff documented a code of 9 for these dates, which directed the reader to the Progress Notes for further explanation. Resident #7 received all other medications as scheduled on these specific dates.Review of Resident #7's Progress Notes lacked clarification as to why the staff did not provide the supplement on the dates listed above.2. Resident #1's January 2026 MAR revealed an order dated 12/27/25 for Loratadine (used to treat allergies) Oral Tablet 10 mg. The instructions directed staff to give 0.5 tablet (5 mg) by mouth once daily for prophylaxis (action taken to prevent disease).Staff documented a code of 9 on 1/1, 1/3, 1/4, 1/5, 1/6, and 1/7, which directed the reader to the Progress Notes for further explanation. Resident #1 received all other medications as scheduled on these specific dates.Review of Resident #1's Progress Notes lacked clarification as to why the staff did not provide the medication on the dates listed above.During an interview on 3/31/26 at 10:30 AM, Staff B, Registered Nurse (RN), commented that marking a 9 on the Electronic Medication Administration Record (EMAR) meant they didn't give the medication. Staff B stated the facility previously directed staff to no longer chart drugs not available and instead must chart on order. She noted if the facility didn't have stock medications available, the office staff sometimes went out to a local store to purchase them.During an interview on 3/31/26 at 11:00 AM, Staff F, Certified Medication Aide (CMA), verbalized she marked a 9 on the EMAR for medications not given and adds a progress note. She stated the facility has been out of medications such as Miralax (a laxative), lidocaine patches (medicated patches for pain), sennoside (a medication used to treat constipation), and acetaminophen (APAP) (a medication used to treat pain and fever). Staff F confirmed she has been out of medication for multiple days at a time and didn't know if someone notified the physician when they didn't have the medications available.During an interview on 3/31/26 at 1:30 PM, the Advanced Registered Nurse Practitioner (ARNP) verbalized she didn't know of unavailable stock medications and no one notified her. She commented she would like to be aware if they didn't have the medication on hand. She added sometimes she ordered a wound treatment and the facility still didn't have the supply a week later.During an interview on 3/31/26 at 2:21 PM, Staff G, Licensed Practical Nurse (LPN), verbalized a 9 on the EMAR meant see progress note. She commented the facility didn't have stock medication available for multiple days. If they didn't have the medication available, she would notify the physician to see if they could replace it with something else on hand.During an interview on 3/31/26 at 2:48 PM, Staff C, RN, verbalized if medication is out of stock, she would write the needed item on a sheet in the medication room for a physician to address. She stated if a pain medication is not available, the Director of Nursing (DON) would sometimes send someone to a local store that sells over-the-counter (OTC) (medication that can be bought without a prescription) medications to get it.During an interview on 4/2/26 at 11:35 AM, the DON confirmed they try to stay on top of having medications available and that a 9 on the EMAR means they didn't give the drug. She stated the facility started a new process of checking and ordering medications on Tuesdays.The Ordering and Receiving Medication policy, dated May 2023, instructed the facility to transmit requests for non-prescription medications and supplies to the pharmacy provider as early as possible to assure that the necessary medications are on hand at all times. The policy recommended assigning a staff member one day a week to check for medications that need reordering before the weekend.

Based on record review, resident, staff, and Advanced Registered Nurse Practitioner (ARNP) interview, the facility failed to revise the Care Plan to include new interventions to address skin integrity and non-compliance with bed rest for one of 16 residents reviewed (Resident #2). The facility reported a census of 93 residents.Findings include: Resident #2's Minimum Data Set (MDS) Assessment, dated 2/10/26, documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS documented diagnoses of Parkinson's Disease, polyneuropathy (damage to multiple peripheral nerves throughout the body), and a left fibula (lower leg bone) fracture. The MDS identified Resident #2 as being at risk for pressure ulcers but indicated no unhealed pressure ulcers or injuries at that time.The Care Plan Focus revised 3/16/26 identified Resident #2 had a potential/actual skin integrity impairment. The Interventions dated 2/5/26 included the following:a. Avoid scratching. Keep hands and body parts from excessive moisture. Keep fingernails short.b. Cushion to wheelchairc. Provide education to prevent skin injuryd. Encourage good nutrition and hydration to promote healthier skine. Identify/document potential causes. Eliminate and resolve when possible.f. Follow facility protocols for treatment of injury.g. Pressure relieving/reducing mattressh. Treatments per providers orders.An Interdisciplinary Team (IDT) Note dated 2/20/26 at 2:15 PM documented a new pressure area on the buttocks. A Nurses Note dated 2/20/26 at 4:10 PM reflected the facility received a new order from the Advanced Registered Nurse Practitioner (ARNP) for zinc oxide (a thick, white cream that creates a waterproof barrier to protect skin from moisture and irritation) twice a day (BID) and as needed (PRN).An ARNP Progress Note dated 2/24/26 directed staff to treat the buttock wound with Calmoseptine (thick paste used to protect skin from moisture and promote healing), reposition Resident #2 frequently, and use a wheelchair cushion.A Nurses Note dated 3/3/26 at 8:53 PM documented a new order for a Wound Clinic referral.An After Visit Summary Note dated 3/6/26 at 11:00 AM from the Wound Clinic ordered Santyl (a debriding ointment) treatments and directed Resident #2 to be on bed rest, up for meals and physical therapy (PT) only.A Dietary Note dated 3/6/26 at 1:17 PM reflected the Dietitian (RD) recommended starting protein supplements and extra eggs due to the deterioration (worsening) of the wound.An After Visit Summary dated 3/19/26 the clinic reiterated Resident #2 should be up for meals only and then returned to bed immediately.An Orders Administration Note dated 3/21/26 at 3:18 AM indicated Resident #2 had an active order to be up for meals only and return to bed immediately every shift.A Nurses Note dated 3/23/26 at 1:59 PM reflected Resident #2 received new orders for doxycycline (an antibiotic) and vinegar soaks daily due to the infection. Staff continued the order of Dakin's (a type of diluted bleach used as a liquid medicine to clean wounds. It helps kill germs and prevents infections so the area can heal.) to pack the wound.During an interview on 3/30/26 at 2:58 PM, Resident #2 stated she believed she got sores from sitting in the wheelchair for too long and that the facility didn't track the skin on her buttocks when she first arrived. She reported a pain level of 7 on a 0-10 scale and stated she would stay up until 10:00 PM if allowed. She noted she should lie down but worried she might not get help to get back up if she did.During an interview on 3/31/26 at 10:57 AM, Staff B, Registered Nurse (RN), stated Resident #2 isn't good at staying on her side and staff have to remind her to change positions even though her bottom hurts.During an interview on 3/31/26 at 11:10 AM, Staff E, Certified Nurse Aide (CNA), stated Resident #2 had been in her wheelchair since breakfast and refused to get in bed, claiming she had things to do.During an interview on 3/31/26 at 11:27 AM, Staff D, CNA, stated Resident #2 directed her own care and sits in her wheelchair from breakfast to lunch.During an interview on 3/31/26 at 1:11 PM, the ARNP stated Resident #2 has cognitive impairment and did what she wants. During an interview on 3/31/26 at 2:48 PM, Staff C, RN, stated Resident #2 hardly ever allowed the staff to assist her to bed and refused daily, failing to adhere to the instruction to only be up for meals.During an interview on 4/1/26 at 2:05 PM, Resident #2 sat in a wheelchair in her room with a cushion in place. Resident #2 stated she told staff they can't force her into bed and acknowledged she should be lying down. She explained she's used 3 different wheelchairs since her admission. Resident #2 reported the facility attempted to find a wheelchair to help her pressure ulcers, but she instructed staff to stop because her current wheelchair's fine and shouldn't be changed. Resident #2 stated she received an air mattress after her pressure ulcer occurred. She reported the wound treatment doesn't really hurt and she won't take pain medication except for Tylenol (a medication used to treat pain and fever). Resident #2 explained she only complied with bed rest when her daughter visited and yelled at her to lie down because she wants to stay on her daughter's good side. Resident #2 noted she wouldn't get into bed even if a nurse told her.During an interview on 4/2/26 at 11:05 AM, Resident #2 returned from the wound clinic and remained in her wheelchair and refused to lie down. Resident #2 said she wouldn't lay down and has sat in her wheelchair since leaving that morning.The Care Plan reviewed on 3/31/26 lacked interventions after 2/5/26 attempted by the facility related to Resident #2's pressure ulcer. The Care Plan did not include 3 attempts to find alternate wheelchairs or the implementation of an air mattress. It also didn't address Resident #2's continued refusal to lie down in bed during the day, despite medical advice. Additionally, the Care Plan failed to include Resident #2's decisions to self-direct her care.During an interview on 4/2/26 at 11:21 AM, the Director of Nursing (DON) stated Resident #2 wasn't compliant (failing to follow medical advice or instructions) and self-transferred. The DON noted Resident #2 had a little confusion but was pretty with it. The DON added the facility should have updated her Care Plan to reflect her refusals. The facility expected the CNAs to round every 2 hours and offer assistance.

Based on observation, record review, staff and resident interviews, and policy review the facility failed to provide Peripherally Inserted Central Catheter (PICC) line dressing changes for 1 of 3 residents reviewed for intravenous lines (Resident #9). The facility reported a census of 93 residents.Findings include: Resident #9's Minimum Data Set (MDS), dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #9 had diagnoses including cellulitis of the buttock (skin infection), anemia (low iron), heart failure, renal insufficiency, diabetes mellitus, and hidradenitis suppurativa (painful skin lumps). The MDS documented Resident #9 had a PICC line in place.The Electronic Medication Administration Record (EMAR) lacked documentation of the transparent semi-permeable membrane (TSM) dressing change for the PICC site scheduled for 3/30/26.During an interview on 3/31/26 at 11:22 AM, Resident #9 reported staff flushed the PICC line but didn't change the dressing. An observation of the PICC site at that time revealed the dressing lacked a date or nurse initials.An observation on 4/1/26 at 10:00 AM showed the same dressing remained in place without a date or initials.During an interview on 4/2/26 at 10:30 AM, the Advanced Registered Nurse Practitioner (ARNP) stated the expectation is for the PICC line dressing to be changed weekly. The ARNP was unaware staff hadn't completed the change for the week.An observation on 4/2/26 at 10:37 AM showed the PICC dressing had a date of 4/1/26 and nurse initials. Resident #9 verbalized staff changed the dressing the previous day.During an interview on 4/2/26 at 11:20 AM, the Director of Nursing (DON) verbalized the PICC dressing should be changed weekly and as needed. The DON stated she wasn't aware the treatment wasn't done for 3/30/26 until 4/1/26.The facility policy titled Central Venous Catheter Dressing Changes revised April 2016 directed staff to change TSM dressings at least every 5 to 7 days and as needed if wet, soiled, or not intact.

Based on record review, staff and resident interviews, and policy review, the facility failed to complete pre-dialysis assessments for 1 of 1 residents prior to their departure for dialysis services (Resident #5). The facility reported a census of 93 residents. Findings include:Resident #5's Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS included diagnoses of type 2 diabetes mellitus (DM) with other diabetic kidney complications, (insufficient insulin production caused high blood sugar that damaged kidney vessels), anxiety, high blood pressure, depression, schizophrenia, seizures, and heart failure (the heart doesn't pump blood efficiently). The MDS reflected Resident #5 received dialysis (a treatment that filters waste, excess fluid, and salt from the blood when kidneys fail).Resident #5's Electronic Health Record (EHR) lacked documentation of a pre-evaluation for dialysis for the month of March 2026.On 3/31/26 at 12:58 PM, Resident #5 verbalized the staff didn't check her vitals before she left for dialysis.On 4/1/26 at 10:20 AM, Staff A, Registered Nurse (RN), commented Resident #5 left about 3:30 AM on dialysis days. Staff A didn't complete an assessment on Resident #5 before they left. Staff A reported she'd never received education on a dialysis assessment.On 4/1/26 at 10:42 AM, the Director of Nursing (DON) verbalized she expected a dialysis assessment to include obtaining the resident's weight and vital signs, observe the fistula site for signs and symptoms of complications, and document in the EHR the evaluation for the dialysis assessment.The End-Stage Renal Disease (ESRD), Care of a Resident policy dated October 2025 instructed staff regarding the general care of residents receiving dialysis treatment. A review of the policy lacked assessment direction of completing a pre- and post- dialysis treatment.

Based on record review, policy review, staff, and resident interviews, the facility failed to ensure 1 of 3 residents received adequate nursing supervision and follow up assessment after a staff member transferred a resident using less than the required staff needed to transfer him as directed in the Care Plan and resulted in him being lowered to the floor (Resident #4). The facility reported a census of 93 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview for Mental Status of 9, suggesting moderate cognitive impairment. The MDS documented he is dependent on staff (staff does all the effort) for transferring from chair or bed to chair transfers. The MDS revealed he had diagnoses of cancer, malnutrition, and septicemia (a life-threatening condition where an infection spreads throughout the bloodstream).Review of Witnessed Fall report for Resident #4 dated 8/4/25 at 10:00 AM informed Resident #4 wife called and reported a CNA lowered Resident #4 to the floor on 8/1/25. The facility implemented an intervention to educate staff on how he is transferred. Record review of the Corrective Action Form dated 8/4/25 for Staff D documented the following verbal warning: Staff D transferred the resident with one assist, despite the resident's mention that they would require a second person for the transfer. As a result, the CNA dropped the resident to the floor without reporting the incident to any nursing staff. During an interview on 10/13/25 at 12:15 PM Resident #4 informed he had a fall at the facility in August 2025 after returning from the hospital. He revealed he told Staff D, Certified Nurse Aide (CNA), she could not do it herself and needed someone else to help her, but Staff D did not listen. He explained Staff D had to lower him to the floor. During an interview on 10/14/25 at 1:18 PM with the Administrator informed Staff D did not notify a nurse when she lowered Resident #4 to the floor on 8/1/25 and he was not assessed by a nurse at the time of the fall. She then informed on 8/4/25 Resident #4 wife informed the facility of the incident on 8/1/25 and the Director of Nursing (DON) provided education for Staff D, and a fall report was completed. During an interview on 10/14/25 at 1:24 PM with the Director of Nursing (DON) informed she provided education on 8/4/25 to Staff D regarding Resident #4 fall on 8/1/25 and no injuries resulted from being lowered to the floor. She informed Staff D informed her she thought he only needed one (1) staff to assist him. She informed staff D was educated all falls even if lowered to the floor need to have assessments completed by a nurse. Review of Resident #4 current Care Plan on 10/14/25 instructed staff starting on 4/30/25 he needs assistance of two (2) staff for transfers. The Care Plan also documented a fall intervention implemented on 8/1/25 informing fall education was provided to staff.Review of the facility policy, Falls - Clinical Protocol, Assessment and Recognition, revised March 2018 instructed the following: Staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc.

Based on observation, electronic health record (EHR), facility policy review, resident and staff interviews, the facility failed to consistently respond to activated call lights within a reasonable amount of time. Residents reported having to wait 1.5 to 2 hours for the call light to be answered. Observations revealed response time had been greater than 15 minutes for 1 of 4 residents observed (Resident #7). The facility reported a census of 93.Findings include:An evaluation for Nursing Section GG completed on 10/3/25 at 10:43 PM documented Resident #7 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts,holds, or supports trunk or limbs, but provides less than half the effort.) for toileting hygiene and toilet transfers. A Brief Interview for Mental Status (BIMS) evaluation completed on 10/10/25 for Resident #7 documented a BIMS score of 15, indicating intact cognition. The Care Plan Report Focus initiated 10/11/23 for activities of daily living (ADL's) indicated Resident #7 has glasses and at times she refused to wear her ankle-foot orthoses (AF0s - lower lime orthoses). The Interventions included: a. Ambulation - walk with an assist of 1 with walker, wheelchair (w/c) for mobility, she could self-propelb.Toileting - Resident #7 required 1 assist. c. Transfer - Resident #7 required 1 assist with walkerDuring an observation on 10/13/25 at 6:45 PM, the lighted hall display on the 300-hall indicated Bath 308 ecall (call light) had been activated. In an interview on 10/13/25 at 6:53 PM, Resident #7 reported staff are not very prompt at responding to call lights. Resident #7 reported she has waited 1 1/2 and up to 2 hours for staff to respond to her needs. Resident #7 reported she transferred herself to the toilet and set a timer to monitor staff response. Resident #7 held her left arm up revealing a device that appeared to be a smart watch. Resident # 7 stated it had been about 10 minutes since she activated her call light. Resident #7 reported when her timer reaches 15 minutes, she pulls the string to reactivate the system. Resident #7 voiced staff care more about charting than caring for residents. During an observation on 10/13/25 at 7:03 PM, the Champion ecall monitor at the nurses' station revealed the following:Bath Ecallroom [ROOM NUMBER]Age: 00:18:02Third resoundDuring an observation on 10/13/25 at 7:05 PM, Staff A, Certified Nursing Assistant (CNA), exited a resident room and pushed a mechanical lift down the hall leaving it outside of room [ROOM NUMBER]. Staff A proceeded to walk by room [ROOM NUMBER] without responding to the activated ecall light. During an observation on 10/13/25 at 7:07 PM, Staff B, Certified Medication Aide (CMA)/CNA, passed by room [ROOM NUMBER] without entering.During an observation on 10/13/25 at 7:08 PM, Staff B and Staff C, Licensed Practical Nurse (LPN) passed by room [ROOM NUMBER] without entering. During an observation on 10/13/2025 at 7:14 PM, Staff A entered room [ROOM NUMBER] to assist Resident #7. In an interview on 10/13/25 at 7:31 PM, Staff B verbalized activated call light response should be within 5 minutes.In an interview on 10/13/25 at 7:36 PM, Staff C verbalized activated call light response is within 5-12 minutes and she assists CNA staff if a second person is needed. In an interview on 10/14/25 at 11:03 AM, the Administrator reported she used call light audit forms to audit call lights that have been identified. The Administrator verbalized the expectation of activated call light response is within 15 minutes or less. The Administrator reported staff are trained on the call light system upon hire. Review of the employee file for Staff B documented a hire date of 12/21/23.The Job Description with a position title of Certified Nursing Assistant directed to assure residents have call lights at hand and answer call lights promptly. The Job Description lacked a definition for promptly. Staff B signed the Job Description on 12/21/23. The Job Description lacked the supervisor signature. The Orientation Checklist: Nursing Assistant for Staff B included the call light system was reviewed on1/4/24. Staff B signed the Orientation Checklist: Nursing Assistant on 1/4/24 verifying all had been reviewed. Review of the employee file for Staff C documented a hire date of 4/10/25. The Job Description with a position title of Charge Nurse - LPN directed to supervise response to resident's call for assistance.The Job Description lacked defining response to resident's call for assistance. Staff C signed the Job Description on 4/10/25. The Orientation Checklist: Licensed Nurses included the call light system. Staff C signed the Orientation Checklist: Licensed Nurses verifying all had been reviewed. The document lacked a date of completion. Review of Call Light Audit Reports revealed 33 rooms with activated call lights had been audited. Audits dated back to 9/9/25 and revealed the facility identified 2 call lights exceeded 15 minutes. The Call Light Audit Report lacked the identified room of 308.Review of the Answering Call Light facility policy reviewed March 2021, indicated the purpose of the procedure is to ensure timely response to the resident's request and needs. The policy directs staff:1. Identify yourself and politely respond to the resident by his/her name (e.g., this is Mrs. [NAME], Mr. [NAME], how may I help you?)a. If the resident needs assistance, indicate the approximate time it will take for you to respond.b. If the resident's request requires another staff member, notify the individual.c. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance. 2. If assistance is needed when you enter the room, summon help by using the call signal. The policy lacked defining timely response to the resident's needs.

Based on observation, staff interviews and policy review, the facility failed to provide a clean, comfortable and homelike environment. The facility reported a census of 92 residents. Findings include:Observation on 7/21/2025 at 11:37 AM in the dining room noted several chairs with dried food and spilled drinks on them. On 7/22/2025 at 8:32 AM witnessed the chairs in the dining room still had dried drinks and dried food on them. On 7/23/2025 at 9:14 AM observed the chairs in the dining room still had dried food and drinks on them. Throughout the dining room [ROOM NUMBER] chairs had dried dirty food and dried liquid spills. During an interview on 7/23/25 at 9:18 AM, Staff B, Housekeeping Aide, and Staff C, Housekeeping Aide, reported if Staff D, Maintenance, is in the building then they didn't clean the dining room. If he didn't work, then they cleaned the floors and clean the chairs. The reported the chairs get cleaned once a day. On 7/23/2025 at 9:21 AM Staff D reported he only cleaned the dining room floor. On 7/23/2025 at 10:08 AM, the Housekeeping Supervisor reported housekeeping deep cleaned the dining room chairs twice a month. While Staff D cleaned the floors. The Housekeeping Aides should check the chairs daily to make sure they are clean. On 7/23/2025 at 10:28 AM observed residents out to group exercise sitting in the dirty dining room chairs. The total 17 chairs in the dining room remained dirty. The facility policy titled Dining Room Audits revised October 2017 documented the facility audited the food and nutrition services department regularly to ensure that resident needs are met and that dining is a safe and pleasant experience for residents. The policy lacked direction on the cleaning frequency and the person/department responsible for cleaning the dining room.

Based on clinical record review and staff interviews the facility failed to accurately document and submit an accurate resident Minimum Data Set (MDS) Assessment for 1 of 2 residents reviewed (Resident #27). The facility reported a census of 92 residents.Findings Include:Resident #27's MDS assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of anxiety, depression, and bipolar (mental health condition characterized by extreme mood swings, cycling between periods of mania and depression). The MDS lacked documentation of Post Traumatic Stress Disorder (PTSD) diagnosis. Review of the Psych Progress Notes for the initial visit dated 5/14/24 and current visit dated 4/15/25 included a diagnosis of PTSD. On 7/22/25 at 12:14 PM, the Administrator reported Social Services should review the Psych Notes to identify the resident's correct diagnoses and include them in the MDS. She reported the MDS should have included the PTSD diagnosis.

Based on clinical record review and staff interview, the facility failed to complete a new Preadmission and Resident Review (PASRR) evaluation as required for 2 of 2 reviewed (Residents #27 and #17). The facility reported a census of 92 residents.Findings include:1. Resident #27's Minimum Data Set (MDS) assessment dated [DATE] indicated the state level II PASRR process didn't consider they had a serious mental illness/intellectual disability or related condition. Resident #27's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of anxiety, depression and bipolar (mental health condition characterized by extreme mood swings, cycling between periods of mania and depression). Resident #27's PASRR dated 4/9/24 documented a short-term approval ending 7/8/24. Resident #27's Electronic Health Record (EHR) lacked documentation of a new PASRR completed. Resident #27's Progress Notes lacked documentation of evidence of effort by the facility working to move them toward a successful discharge to a lower level of care on or before the short-term approval end. Review of the psych Progress Notes from initial visit dated 5/14/24 and current visit from 4/15/25 documents a diagnosis of PTSD and the PASRR lacked documentation of the diagnosis. On 7/22/25 at 12:00 PM, the Administrator reported Social Services as responsible for completing the PASRR assessments. She reported they identified the concern during their mock survey. When questioned if they completed a new one, she responded they still had it as a work in progress. She reported Social Services should document on discharge planning in the process notes. On 7/22/25 at 12:14 PM, the Administrator reported on 5/22/25 in the mock survey the facility noted a new PASRR needed to be completed. She reported it should have been done within the last 60 days but still was not completed. She further reported the social services should be reviewing the psych notes to make sure the correct diagnoses are identified and on the PASRR. 2. Resident #17's MDS assessment dated [DATE] included diagnoses of anxiety disorder, depression, bipolar disorder, and psychotic disorder. The MDS reflected Resident #17 received antipsychotic and antidepressant medication in the lookback period. The Care Plan Focus area dated 3/21/23 reflected Resident #17 had a behavior problem related to hallucinations and delusions. The situation caused Resident #17 to wander/exit seek, had paranoia, confusion, tearfulness, and made accusatory statements. The Care Plan Focus revised 5/21/24 identified Resident #17 had a risk for side effects from antipsychotic, antidepressant, and antianxiety drug use. In addition, Resident #17 had anxiety disorder, delusional disorder, hallucinations, bipolar, mood affective disorder, major depressive disorder severe with psychotic symptoms. Resident #17's Medical Diagnosis Sheet reviewed 7/22/25 included the following mental health related diagnoses: a. Major depressive disorder, recurrent severe with psychotic symptoms dated 5/16/22 b. Bipolar disorder manic without psychotic features dated 2/1/23 c. Unspecified mood disorder dated 2/1/23 d. Hallucinations, unspecified dated 2/1/23 e. Delusional disorder dated 2/1/23 f. Mild cognitive impairment /uncertain or unknown etiology dated 5/16/23 g. Anxiety disorder dated 5/16/23 Resident #17's Notice of PASRR Level 1 Screen Outcome dated 6/16/23 reflected a level I determination of level I negative, no status change. The PASRR only included the diagnosis of unspecified mood disorder. The rationale indicated Resident #17 didn't have a PASRR disability present because of no change occurred and there isn't evidence of a PASRR condition of an intellectual/developmental disability or serious behavioral health condition. If a status change occurs, then an updated Level I must be submitted by the nursing facility to report that change.

Based on clinical record review, policy review and staff interview, the facility failed to revise the resident care plan for 1 of 22 residents reviewed (Resident #27). The facility identified a census of 92 residents. Findings include:Resident #27's MDS assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of anxiety, depression, and bipolar (mental health condition characterized by extreme mood swings, cycling between periods of mania and depression). The MDS lacked documentation of Post Traumatic Stress Disorder (PTSD) diagnosis. Resident #27's psych Progress Notes from the initial visit dated 5/14/24 and current visit dated 4/15/25 documented a diagnosis of Post Traumatic Stress Disorder (PTSD). Resident #27's Physician Recommendations related to the antidepressant on 7/8/25 documented Resident #27 had a history of severe depression with a suicide attempt at another facility. Resident #27's Care Plan revised 4/2/25 lacked documentation and interventions for PTSD and the history of suicide. On 7/24/25 at 9:24 AM Staff A, Social Services Coordinator, reported Resident #27's Care Plan should include PTSD and her history of suicidal ideations. The other Social Services Coordinator should review the notes in the chart from the physicians and update the Care Plan to reflect her mental health needs.

Based on clinical record review and staff interview, the facility failed to notify the Long-Term Care (LTC) Ombudsman for 1 of 1 resident who transferred to the hospital (Resident #65). The facility reported a census of 81 residents. Findings include: Resident #65's Clinical Census report reviewed 9/5/24 reflected the following: a. 7/29/23: discharged to the hospital; returned 7/31/23 b. 9/17/23: discharged to the hospital; returned 9/22/23 c. 10/6/24: discharged to the hospital; returned 10/10/23 d. 2/1/24: discharged to the hospital; returned 2/7/24 e. 3/21/24: discharged to the hospital; returned 3/24/24 The clinical record lacked documentation of notification to the LTC Ombudsman of Resident #65's discharges to the hospital as required by Federal regulation. During an interview on 9/5/24 at 11:36 AM, the facility Social Worker (SW) reported she is the person responsible for sending the notification to the Ombudsman for discharges. The SW acknowledged she didn't notify the Ombudsman Resident #65's discharges to the hospital. She explained she expected they get notified. During an interview on 9/5/24 at 1:17 PM, the Director of Nursing (DON) stated the facility didn't have a policy for notification to the Ombudsman, they follow regulations.

Based on observations, interviews, and record review, the facility failed to bathe a resident on a frequent and consistent basis for 1 of 1 resident reviewed (Resident #140). Resident #140 only received 1 bed bath in the 2 weeks since her admission. The facility reported a census of 81 residents. Findings include: Resident #140's Minimum Data Set (MDS) assessment dated [DATE] listed their admitted as 8/21/24 from a short-term general hospital stay. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #140 required partial/moderate assistance for showering/bathing. The MDS included diagnoses of a fracture (broken bone) and pain in left leg. The Care Plan Focus area related to activities of daily living (ADL's) dated 8/21/24 listed a Goal for Resident #140 to participate during her ADLS as her condition allowed. The Interventions reflected the following: a. An immobilizer on her left lower extremity, with no knee flexion (bending in) for 6 weeks. b. Resident #140 required assistance from 1 staff for bathing. An Appointment/Visit Note dated 9/4/24 at 12:02 PM, indicated the Ortho (orthopedics surgical procedures on your bones, joints, and surrounding tissues and structures) provider that day. The Ortho provider gave orders for TTWB (toe touch weight bearing) to her LLE (left lower extremity) and use an immobilizer (keep knee in straight) while up. The order instructed to keep the leg extended at all times and she may remove the brace to wash her leg, if her leg can stay extended. They gave her a cortisone (helps to reduce swelling medication) injection to her R (right) knee that day, no restrictions to RLE (right lower extremity). A Doctor's Order dated 9/4/24 at 2:00 PM, directed Resident #140 must have an immobilizer to her left lower extremity while up with her leg extended at all times. The order included staff could remove the brace to wash her leg, if she could keep her leg extended. On 9/3/24 at 2:05 PM, observed Resident #140 sitting in a recliner with a leg brace on her left leg. Resident #140 reported she had a concern. She explained a staff member tried to take off her brace to give her a shower. Resident #140 told the staff member she couldn't take her brace off. She stated the staff person then gave her a bed bath. Resident #140 reported it as the first bed bath she received in the 2 weeks she lived at the facility. The point of care (POC) response history lookback for the previous 30 days printed 9/4/24 related to ADL Self-Care - Shower/Bathe self on Mondays and Thursdays on the second shift reflected the staff provided total assistance for Resident #140's bath on 9/2/24. The remaining documentation reflected on 8/22/24, Resident #140 refused a bath, then on 8/29/24 and 9/4/24 indicated not applicable as the task not attempted. On 9/4/24 at 4:36 PM, Staff B, Certified Nurse Aide (CNA), stated he worked on 8/29/24 on the second shift. He explained he shouldn't have documented the bath as not applicable. He added if he did, it must be one of those zoned out mistakes on his end. Staff B didn't remember giving Resident #140 a shower that. Staff B didn't remember Resident #140 refusing a shower from him. Staff B stated he didn't offer Resident #140 a shower. He explained he showed up a few hours after the shift started and worked from 4:00 PM to 10:00 PM, as he had college classes until 3:15 PM. Staff B denied knowing Resident #140 needed a shower. On 9/5/24 at 10:14 AM, Staff C, CNA, reported she didn't remember documenting not applicable for Resident #140's shower. She said she must have hit the button on accident, as she never gave or offered Resident #140 a shower. On 9/5/24 at 8:45 AM, Resident #140 explained someone offered her a shower the day before. She stated they came in and said we are going to shower you now. She stated she wasn't ready for a shower. The staff told her she could have a shower because she could take off her brace from her leg now. Resident #140 reported she told the staff member she didn't feel comfortable yet to take a shower and requested to have a bed bath instead later that night after her company left. Resident #140 stated she had visitors in the room and wanted to visit more. She added no one had mentioned her taking a shower or bed bath that day to her, so she didn't know she should have one. Resident #140 explained a staff person came back into her room after this and had her sign a statement. Resident #140 stated she didn't know for sure what she signed but thought it might be something about refusing her shower. After her visitor left, she asked the CNAs if she could talk with the staff person who had her sign something. The CNAs left and when they returned to the room, they stated that the staff person's door was closed and they were gone for the day. On 9/5/24 at 9:00 AM, the Director of Nursing (DON) came in with the following 2 Internal Investigation Witness Statements. The DON stated that her ADON had the resident sign a witness statement regarding refusal of shower. The DON stated that she, the DON, then talked with the resident on this day and had her sign a Witness Statement as well. The DON was then asked if they would have documented bed baths in the tasks. She stated yes. a. An Internal Investigation Witness Statement dated 9/4/24 signed by Resident #140 reflected a statement that the girls always give her a bed bath every night. She didn't want to get a shower with her leg, so the girls give her one every night. b. An Internal Investigation Witness Statement dated 9/5/24, reflected the DON interviewed Resident #140 about a shower incident. The statement indicated Resident #140 got a bed bath the night before and they did a good job. The statement documented she still felt a little bit leery about taking a shower as they just took her stitches out. She added she didn't feel ready for a shower yet. The statement included Resident #140's signature. Following the conversation, the ADON came into the room and reported Resident #140 did say she had a bed bath every night. When told Resident #140's electronic health record didn't reflect that and she reported she received 2 bed baths since her admission which included the one from the night before, the ADON responded that wasn't what Resident #140 told her. When told Resident #140 didn't know for sure what she signed but thought it had to do with her refusing a shower the night before, the ADON repeated Resident #140 said she got a bed bath every night. The DON returned shortly after the above conversations. She acknowledged the concern Resident #140 reported only having 2 bed baths and the documentation of not applicable regarding showers on 2 of the 4 entries reviewed. A Bath, Shower/Tub policy revised on February 2018, defined the purpose as to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. The policy instructed to chart the date and time they performed the shower or tub bath. The name and title of the individual(s) who assisted the resident with the shower/tub bath. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. The signature and title of the person recording the data. The policy indicated to notify the supervisor if the resident refused the shower/tub bath and/or other information in accordance with facility policy and professional standards of practice.

Based on interviews, observations, and record review, the facility failed to provide safety interventions for 1 of 4 residents reviewed (Resident #140). The facility was aware that Resident #140's wheelchair brakes didn't work. They continued to transfer her in and out of her wheelchair without repairing the wheelchair brakes or replacing the wheelchair with a different wheelchair which had working brakes. The facility reported a census of 81 residents. Findings include: Resident #140's Minimum Data Set (MDS) assessment dated [DATE] listed their admitted as 8/21/24 from a short-term general hospital stay. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #140 required partial/moderate assistance for showering/bathing. The MDS included diagnoses of a fracture (broken bone) and pain in left leg. The Care Plan Focus area related to activities of daily living (ADL's) dated 8/21/24 listed a Goal for Resident #140 to participate during her ADLS as her condition allowed. The Interventions reflected the following: a. An immobilizer on her left lower extremity, with no knee flexion (bending in) for 6 weeks. b. Resident #140 required assistance from 1 staff for bathing. An Appointment/Visit Note dated 9/4/24 at 12:02 PM, indicated the Ortho (orthopedics surgical procedures on your bones, joints, and surrounding tissues and structures) provider that day. The Ortho provider gave orders for TTWB (toe touch weight bearing) to her LLE (left lower extremity) and use an immobilizer (keep knee in straight) while up. The order instructed to keep the leg extended at all times and she may remove the brace to wash her leg, if her leg can stay extended. They gave her a cortisone (helps to reduce swelling medication) injection to her R (right) knee that day, no restrictions to RLE (right lower extremity). A Doctor's Order dated 9/4/24 at 2:00 PM, directed Resident #140 must have an immobilizer to her left lower extremity while up with her leg extended at all times. The order included staff could remove the brace to wash her leg, if she could keep her leg extended. On 9/3/24 at 2:05 PM, observed Resident #140 sitting in a recliner with a leg brace on her left leg. On 9/4/24 at 1:56 PM, Resident #140 said her wheelchair (w/c) brakes didn't work. While at her ortho appointment, they told her to tell the facility her brakes didn't work. She reported she hadn't said anything about it but, the staff said something about it as they put their foot behind the wheel to stop the w/c from rolling back when they transferred her in and out. She declared she didn't want to fall again. That morning a gal from therapy transferred her and she did a wonderful job. She said the night before 2 gals came in who were difficult to understand, but they understood her because she told them to use the gait belt and they did. She said her ortho appointment went really well that day. Because she had a pain pill after she returned from her appointment that made her a little sleepy, so she hadn't relayed that she needed a different w/c to anyone yet. Resident #140 sat in her recliner with her legs elevated. On 9/4/24 at 3:23 PM, Staff E, Registered Nurse (RN), explained she gave direction to the 2 day shift Certified Nurse Aides (CNAs) to swap the w/c out for a different one. She confirmed she knew the w/c brakes didn't work and she told the CNAs to swap it out for one with working brakes. Staff E verified the w/c in the room was the one that needed to be swapped out for a new one. Staff E told Resident #140 that she would swap it out and took the w/c out of the room to change it. Staff E stated that she told the CNAs to change her w/c out that morning probably around 11:00 AM or 12:00 PM. On 9/5/24 at 8:45 AM, Resident #140 stated it was funny but after mentioning the wheelchair brakes to the surveyor, a half an hour later they came in and switched out her wheelchair. She stated they talked about how the wheelchair brakes didn't work and how she needed a different wheelchair since her admission. She stated the nurses, CNAs, the ortho clinic staff, and even the transport driver who took her to her ortho appointments talked about how she needed a different wheelchair with brakes that worked. On 9/5/24 at 11:01 AM, Resident #140 verbalized appreciation for the brakes being fixed on her wheelchair yesterday. She said that morning when the therapy staff took her to therapy, they said they fixed the wheelchair. On 9/5/24 at 11:02 AM, Staff F, Certified Occupational Assistant (COTA), stated she took her to therapy that morning. She reported being happy when she noticed they fixed the w/c brakes. Staff F explained they found Resident #140's wheelchair brakes not working sometime the previous week or the week before. She thought another therapy worker put in a work order for someone to fix them sometime last week. She declared it challenging to transfer Resident #140 in and out of the w/c with the brakes loose. Staff F said they had discussions about the wheelchair brakes needing fixed but they couldn't find any documentation of the conversations nor have documentation of a work order. On 9/5/24 at 11:30 AM, the Maintenance Supervisor stated he didn't receive a work order to fix Resident #140's wheelchair brakes. He stated he went through all of his work orders and couldn't find any for Resident #140. He added he didn't do anything with Resident #140's w/c. He reported if he received a work order to fix Resident #140's or any residents' wheelchair brakes he would have done them immediately. He stated that he wouldn't wait around to fix wheelchair brakes that didn't work because of the possibility that broken brakes could cause harm to a resident. On 9/5/24 at 1:18 PM, the Director of Nursing (DON), provided the Activities of Daily Living (ADLs), as the policy for the w/c brakes not functioning properly and pushing residents in w/c's with their feet on the floor. She reported it as the closest policy the facility had to cover the incident. This DON acknowledged the concern with the incidents. An Activities of Daily Living (ADLs), Supporting policy revised March 2018, directed staff to provide residents with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently, will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. Policy Interpretation and Implementation a. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) don't diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. The facility will provide the appropriate care and services for residents unable to carry out their ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking). b. Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression.

Based on clinical record review, interview and policy review, the facility failed to serve the correct diet for 1 of 2 residents reviewed for nutrition (Resident #41). The facility reported a census of 81 residents. Findings include: Resident #41's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Resident #41 required set up help for eating. The MDS included diagnoses of cardiorespiratory (heart and lung) conditions, heart failure, renal insufficiency (impaired kidney function), arthritis, stroke, malnutrition (inadequate nutrition), non Alzheimer's dementia, and esophageal obstruction (blockage in the throat). The Care Plan Focus dated 10/19/23, reflected Resident #41 had a diet order for regular/no added salt (NAS), mechanical soft texture (a type of texture modified diet for people who have difficulty chewing and swallowing. Foods may be pureed, ground, finely chopped, or blended to make eating safer), and thin liquids. The Care Plan Interventions instructed the staff to provide her with meals that are within her diet. The Physician Order dated 10/19/23 listed a diet texture of mechanical soft. During an interview on 9/3/24 at 11:35 AM, Resident #41's family member stated Resident #41 has a mechanical soft diet. They explained the facility gave them meat not ground when the family member visited. One time they served Resident #41 a chicken leg, but Resident #41's family member sent it back. In the past July, the facility didn't grind the chicken leg and it had the bone intact. Resident #41 ate in her room. Also, in July the facility gave Resident #41 unground ham and fish. The family member reported she talked to the Administrator about this. During an interview on 9/4/24 at 11:30 AM, the Administrator denied any memory of the family member coming to him about how Resident #41 received their diet texture and added he didn't have knowledge of a grievance filed. The Administrator declared it a concern if a resident received food not according to their diet order. The Administrator expected the staff to follow diet orders. During an interview on 9/4/24 at 12:35 PM, Resident #41's family member reported she had pictures of the incorrect texture of food the facility served to Resident #41. Resident #41's family member stated she talked to the Administrator in July, after she took some pictures, she showed the Administrator the pictures of the unground meat. The Administrator told her that maybe they didn't grind up the fish because it is flaky. Resident #41's family member stated she stopped the Administrator in the hallway to talk to him, he stated he would look into it. A review of the photographs taken by Resident #41's family member revealed a plate containing two fillets of fish, a piece of bread with butter and rice. The picture didn't have a ticket next to it, they stated they took in July of that year. The second picture showed a plate with two pieces of dry bread with slices of ham in pieces and a whole piece of cheese. The picture included a ticket next to the plate with a date of 7/22/24, Resident #41's name at the top and food listed as 1 Milk chocolate (8 Fl oz), 1 Ham Sandwich Ground (4 oz), 1 Cream potato soup (6 oz), 1 Mashed Potatoes (1/2 Cup), 1 Crackers (2), 1 Pudding (1/2 cup), 1 Strawberry Shortcake (1 slice), 1 Iced tea (8 Fl oz). Under this is listed Diet: Mechanical Soft, *Regular/NAS Diet, Fluids Thin TN0. During an interview on 9/4/24 at 12:59 PM, the Dietary Manager (DM) advised knowledge of the residents' diets because the nurses brought the orders and it is printed on their meal ticket. Resident #41 is on a mechanical soft diet, she preferred soft foods as she has a harder time eating. The DM defined a mechanical soft diet as things easy to chew, are in small pieces, or ground up. The DM stated all of the meat served to Resident #41 should be ground up. The DM stated fish is not put in the grinder, however should be cut it up in small pieces. Chicken is ground up, it shouldn't be served on the bone. The DM advised it is possible the cook didn't follow the resident's diet order and served her incorrect food texture in July of that year. The DM stated they expected the resident's food meet the criteria for mechanical soft and advised chicken served on the bone, fish not cut up in small pieces up or ham not ground wouldn't fit the criteria for mechanical soft. The DM stated a concern for the resident choking. The DM stated she expected the facility to follow diet orders. During an interview on 9/5/24 at 1:03 PM, the DM advised the corporation sends out the spreadsheets for the diets, they follow the spreadsheet for the type of diet a resident received. The DM reviewed the spreadsheet for chicken on the bone for a mechanical soft diet, this documented for the chicken to be ground, off the bone. The DM stated a resident on a mechanical soft diet would receive chicken off the bone that they processed in the robot coupe (specialized blender) and ground, she usually used a chicken breast for this with no skin. The spreadsheet for a ham sandwich for a resident on a mechanical soft diet documented for the ham to be ground. The DM stated this would be done by placing the ham in the robot coupe to grind it and then placing the ground up ham on the bread. The spreadsheet for fish (tilapia fillet) for a mechanical soft diet documented for the fish to be ground. The DM stated fish didn't grind up well in the robot coupe, the fish should be broken apart into small pieces to be served to the resident on a mechanical soft diet. The Orders Designating Diet policy, revised September 2017, directed the physicians shall provide appropriate diet orders and the facility should provide the residents appropriate nutrition and hydration.

Based on observation, clinical record review, and staff, resident, and visitor interviews, the facility failed to respect dignity for 1 of 5 residents reviewed (Resident #2). On 1/20/24-1/21/24 facility staff were aware that Resident #2's call light was not working. Resident #2 was incontinent and staff failed to provide a means for the Resident to contact staff for toileting, and assistance with other needs. The facility reported a census of 94 residents. Findings include: In an interview on 2/13/24 at 11:20 a.m. a visitor reported on 1/20/24 she was at the facility and found Resident #2's bedside call light was not working. Stated she was in the resident's room for 2.5 hours on the evening shift and no staff entered the room. The visitor further stated she had informed the nurse on duty and was told that nothing could be done on the weekend to repair the call light. The visitor reported that during her visit Resident #2 was incontinent, toileted himself, and would have fallen if she hadn't been there. The visitor further expressed concern that the Resident was unable to get help to get his pants pulled up and went out into the hallway half dressed to get help from staff. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS further documented the resident required set up or clean up, and supervision or touching transfer assistance for toileting. Review of a re-admission assessment completed on 2/2/24 documented the resident was alert and oriented to person, place, time, situation, and forgetful. In an interview on 2/13/24, Resident #2 responded that he recalled the weekend that his call light was not working and he couldn't get assistance from staff and that had made him feel low. The Care Plan dated as initiated on 1/4/24 revealed the resident was identified at high risk for falls and required assistance with Activities of Daily Living (ADL's). The Care Plan directed staff the resident required assistance of one staff for toileting and transfer, and to anticipate and meet the residents needs to complete cares with dignity and safety due to behavior problems. On 1/31/24 at 9:00 a.m., the residents call light in his room was observed functioning properly. In an interview on 2/1/24 at 1:59 p.m. Staff A, Registered Nurse (RN) reported on 1/20/24 she was informed by a visitor that Resident #2's call light was not working. Staff A stated that she had not contacted maintenance or set up formal frequent checks or monitoring. Staff A responded that she should have called maintenance and initiated 15-minute checks and closer monitoring when she determined the call light was not working. On 2/1/24 at 1:52 p.m. Staff B, Licensed Practical Nurse (LPN) stated that she had worked the day shift (6:00 a.m.-2:00 p.m.) on 1/20/24 and 1/21/24 and was unaware there were any concerns with Resident #2's call light. Staff B responded that she would expect the staff to notify her when a call light was not working properly. Staff B further stated she would have verified the call light was not working, called maintenance to fix, and provided closer monitoring until the call light was repaired. Staff B responded Resident #2 was continent and able to use the call light to inform staff when he needed assistance and to use the bathroom. On 1/31/24 at 11:19 a.m., the Maintenance Supervisor verified Resident #2's call light was repaired on 1/21/24 by replacing the cord. Stated he is available 24 hours/7 days a week and would expect to be notified right away when there is a safety concern like a call light not working. The Maintenance Supervisor stated that he had not been called and had only been made aware on 1/21/24 when he was at the facility for another issue. In an interview on 2/1/24 at 2:15 p.m. the Administrator stated he would expect staff to call maintenance on call to repair a call light not working properly and to implement measures to provide closer monitoring. The Administrator stated the facility had no documentation of routine, more frequent, or closer monitoring for Resident #2 when his call light was known to not be functioning at the bedside on 1/20/24-1/21/24. A policy titled Answering the Call Light revised 3/2021 identified the procedure is to ensure timely responses to the resident's requests and needs and directed the staff to be sure that the call light is plugged in and functioning at all times and to report all defective call lights to the nurse supervisor promptly. Review of an Employee Coaching Worksheet dated 2/1/24 documented Staff A, RN received verbal coaching which included direction to call maintenance right away for call light problems, place the resident on 15-minute checks, and offer to move the resident to another room. Review of a facility worksheet titled Weekend Manager revealed general duties included: Check maintenance box at the nurse's station for any work requests that need to be addressed immediately, call lights not working is an emergency. The facility was unable to provide a facility policy related to dignity or residents rights.

Based on clinical record review, staff, family, and provider interviews the facility failed to provide ongoing assessments, intervention, and physician updates to inform of an ongoing change in condition, for 1 of 6 residents reviewed (#1) who exhibited left leg swelling, intermittent pain, warmth, and a lump behind the left knee which resulted in the resident being transferred to a local emergency room with a blood clot on 6/6/23 after discharge from the facility to an Assisted Living Home on 6/5/23. The facility reported a census of 89 residents. Findings include: According to the Quarterly Minimum Data Set (MDS) dated [DATE] Resident #1 had admitted to the facility on [DATE] with diagnoses including malnutrition, muscle weakness, and COPD. The resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 indicating moderately impaired cognitive ability. The resident required extensive assistance of 1 staff for transfers, dressing, and personal hygiene. Review of Resident #1's Care Plan dated as created 6/1/23 identified the resident experienced the presence of frequent pain and directed staff to monitor for worsening pain symptoms and report to the physician. Review of electronic Progress Notes for Resident #1 included the following documentation related to left lower extremity: 5/26/23 at 11:20 a.m. Resident reported issues with the left side of her body being numb and a slight headache. Resident assessed, no facial drooping and hand grasps equal. Resident denies still having symptoms. 5/28/23 at 11:05 a.m. Resident complains of feeling weak while standing, family reported resident having calf pain, Homan sign (considered a sign of a deep vein thrombosis or blood clot of a deep vein) negative to Right leg. 5/29/23 at 10:37 a.m. Resident has 1+ edema to left lower extremity, no pain or warmth noted upon palpation. 5/30/23 at 8:42 a.m., Staff A, Licensed Practical Nurse (LPN) documented: Resident complains of pain to the back of her left knee. Area was warm and tender to touch. Question if palpated a very small lump to the posterior medial aspect of the knee. Call out to Provider AA. 5/30/23 at 11:10 a.m., Staff A, LPN documented: Area is no longer warm or tender to touch, denied pain currently. Family requested no intervention now, as resident currently being assessed by assisted living representative. 5/31/23 at 10:44 a.m. Staff B, Registered Nurse (RN) documented that family does not want resident to go out on appointment, call placed to Provider AA to see if she would come and see resident in the facility. 5/31/23 at 2:30 p.m. Staff B, RN documented Provider AA not able to come and see resident at facility, but is ok with resident seeing another group provider. 5/31/23 at 3:33 p.m. Edema to Left Lower Extremity is down. 6/3/23 at 8:47 a.m. Left leg is noted with 1+ edema, no erythema (redness) or increased warmth noted. 6/3/23 at 9:10 p.m. Staff C, RN documented called to room by patients two daughters. Concerned about swelling to the left leg. Assessment of left lower extremity, noted mild swelling. Denies pain upon palpation, no abnormalities felt, skin temperature normal. Resident given an ice pack to place behind knee and assisted to elevate. Temperature 100.8, Tylenol given and effective. 6/5/23 at 9:26 a.m. Discharge summary: resident left via private vehicle with family. Review of the electronic record temperature summary included the following: 6/3/23 at 7:25 p.m. 100.8 degrees Fahrenheit, forehead reading 6/4/23 at 3:54 p.m. 100.2 degrees Fahrenheit, forehead reading 6/4/23 at 7:06 p.m. 100.4 degrees Fahrenheit, forehead reading Review of a document titled Transitional Care Team Discharge Summary, completed by Provider BB, on 6/2/23 at 10:00 a.m. included: Resident has slight edema in her left leg, mild pain in her left calf. TED hose (compression stockings) have been ordered to be applied. Review of a Physician's Order Sheet and Progress Note dated 6/2/23 documented Provider BB ordered [NAME] hose on daily, OK to discharge to assisted living facility. Provider BB documented left leg +1 edema, pain in the left calf, no redness or warmth. Review of a Health Care Provider's Order sheet, dated as written on 6/2/23 at 10:23 a.m. by Provider AA revealed a new order for compression stockings (medium) knee high, and Lasix (diuretic) 20 mg daily as needed for edema. Review of Occupational Therapy Treatment Encounter Notes included the following: 5/30/23 Patient reporting discomfort in the neck, back, and left lower extremity. Pain with movement rated 8/10. Patient limited by pain to session interventions. 5/31/23 Nurse came in to check on resident left lower extremity due to pain. Resident not agreeable to completing STS (sit to stand) transfer to a 2 wheeled walker. Pain with movement rated 5/10. 6/1/23 Session missed as resident being assessed. 6/2/23 Resident agreeable to theraband exercises for bilateral upper extremity strength, rated pain at rest 3/10, location left lower extremity. Review of Provider AA's clinic encounter notes included: Clinic RN attempted to return a call to the facility on [DATE] at 9:18 a.m. Noted on hold too long. 5/31/23 at 10:55 a.m. Clinic RN documented Staff B, RN had reported that resident on skilled level of care and a provider has to stop in and see her at the facility. Wants to know if Provider AA will see her or if another provider is available to see her. 5/31/22 at 2:24 p.m. Provider AA instructed to call facility and let know that Resident will either need to come in for an appointment or see another provider prior to her discharge. 5/31/23 at 2:28 p.m. clinic medical assistant noted had spoken to Staff B, RN and she will have Provider BB take care of it. 6/1/23 at 3:10 p.m. clinic medical assistant noted family had questioned if anyone had contacted Provider AA regarding lower extremity edema and possible an order for compression stockings. 6/2/23 at 7:57 a.m. Provider AA requested clinic staff call facility with a verbal order for compression stockings plus Lasix 20 mg as needed for edema. 6/2/23 at 9:39 a.m. clinic medical assistant spoke to facility staff nurse who reported Resident #1's left ankle does have some edema, denied pitting edema. Stated that resident would benefit from compression stockings. Review of a facility form titled Concern Investigation form, dated 6/6/23, provided by the Director of Nursing (DON) documented that a family member informed the facility that Resident #1 had been taken to the emergency room and has a blood clot behind her left leg. Additionally, documented family had told multiple nurses about the pain in the left leg During an interview on 11/8/23 at 2:15 p.m. Staff A, LPN recalled on 5/30/23 at 8:44 a.m. Resident #1 had complained of pain to the back of the left knee. Noted the area was warm and tender to touch, confirmed she had found a small lump behind the knee, and the left lower leg was swollen. Responded that she had been concerned about a blood clot, so had called Provider AA, but had not received a return call. When asked what she would expect to have done in response to a suspected blood clot, she responded that she should have made a mark and measured the circumference of the leg at the mark so they could monitor, however stated she had not measured. Further responded that she should have checked for a positive Homan's sign, which she thought she may have done, but should have documented and had not. Additionally stated, would be expected to assess skin temperature, look for redness, swelling, pain, notify provider, and put on report for the next shift. Staff A had further documented prior to the end of her shift that area was no longer warm or tender to touch. Stated when you call a provider and don't hear back would assure communicated to the next shift, and would expect them to follow up. Staff A stated she couldn't recall if she had passed on the information through daily shift report. On 11/9/23 at 3:37 p.m. Staff A, LPN clarified that she had shared her assessment when she notified the provider's office on 5/30/23. The facility was unable to provide daily report sheets for 5/26/23-6/5/23. During an interview on 11/8/23 at 2:52 p.m., Staff B, RN/Assistant Director of Nursing (ADON) recalled that she had been alerted on 5/31/23 that Provider AA was unable to see Resident #1 at the facility to complete a discharge assessment and documented would attempt to get a provider to see in house as family didn't want resident going out for an appointment. The ADON confirmed that Provider BB had seen resident on 6/2/23. Reviewed with the ADON that Staff A reported had been concerned about a blood clot on 5/30/23 and had made a call to the provider, but hadn't received a return call. The ADON responded that if suspected a blood clot and hadn't heard back from the provider would send to the emergency room . Would additionally expect to be on report for ongoing monitoring through assessment which would include measuring the circumference of the leg, Homan's sign, pain, and redness which she would expect to be documented. The ADON confirmed she had not been aware that Staff A had been concerned about a blood clot when had placed a call to the provider. Stated had she been aware she would have assessed the leg. In an interview on 11/8/23 2:42 p.m. Staff C, RN confirmed had documented on 6/3/23 at 9:10 p.m. that resident had swelling of the left leg, ice pack for behind knee and elevate. Staff C responded that she usually reviews documentation for previous concerns but could not recall that she had looked back or had been made aware of concerns regarding pain or swelling of left leg or the possibility of blood clot. Staff C recalled that the pain in the left leg had been all over, not specific. Stated that there had been mild swelling, but not pitting edema, denied that she had measured the leg. Stated that when you suspect a blood clot you would expect to assess for tenderness, pain in the calf, Homan's, redness, measure circumference, continue to monitor, contact the provider, and document. Stated that with a suspected blood clot wouldn't expect to apply an ice pack. In an interview 11/9/23 at 9:20 a.m. Provider BB stated she was asked to do a discharge assessment and summary on Resident #1 prior to her discharging to an Assisted Living facility. Provider BB stated that she does not recall being informed of any concerns with left leg pain or swelling prior to completing the assessment. Confirmed she had documented plus 1 edema and calf pain in the left leg. Responded that it would have been helpful to have that information when completing her assessment and might have changed her direction to the staff. Might have ordered a doppler rather than compression stockings. Stated the nurse usually gives her a brief summary before she sees the resident, does not recall the day of the assessment. Additionally, stated was not aware of pain in left leg when standing, as documented by therapy when completing a one person assist. Stated she was seeing resident in lieu of Provider AA who does not come to the facility, and family had not wanted the resident to have to leave the facility. During an interview on 11/9/23 at 2:15 p.m. Provider AA stated on 5/31 the ADON had called the office nurse multiple times attempting to schedule a last visit before discharge for Resident #1, with the final result that Provider BB was scheduled to see. Provider AA denied there was any record of a call from the facility informing of left lower leg pain, swelling, warmth, or a lump. Provider AA reviewed notes that resident discharged to an Assisted Living facility on 6/5/23 and on 6/6/23 was taken to the emergency room by family due to swelling, pain, and warmth over the last 5 days. Provider AA stated she absolutely, 100 percent would have expected to be informed of the left side lower extremity swelling and pain and would have sent them out to the emergency room . Provider AA reported resident diagnosed with a Deep Vein Thrombosis (DVT), blood clot, of the femoral and of the popliteal vein on 6/6/23 in the emergency room , after she had been discharged to assisted living on 6/5/23. Provider AA reiterated that she would have expected to have been informed by the facility and stated that her opinion is the symptoms that Resident #1 had experienced at the facility were related to the DVT found at the emergency room . In an interview on 11/9/23 at 2:48 p.m. the Admission Nurse from the Assisted Living facility stated she had completed the admission assessment virtually, and had not been provided any information that the resident had left leg pain until she arrived at the assisted living. Therapy assessed upon admission, was informed of leg pain and swelling and when continued the next day was informed by family that resident had been experiencing for 7 days, was sent to the emergency room . In an interview on 11/14/23 at 10:39 a.m. family reported they had been very concerned about the swelling, pain, and a lump in resident's left lower leg from 5/27/23-discharge. They had reported to multiple nurse's and felt they had not taken it seriously. When transferred to assisted living, Resident #1 was assessed and there was concern about the pain, and swelling of the left leg. On 6/6/23 the pain and swelling continued and the resident was taken to the emergency room where they found a blood clot. Review of a policy titled: Change of Condition/Hot Chart Protocol, Nursing Guidelines and Procedure Manual, January 2015 edition, provided by the DON as a facility policy, revealed the licensed nurse is responsible to provide care to residents through nursing assessments, interventions, and appropriate follow up. A definition of condition change included: an alteration from normal status. Could include, but not limited to: skin changes, vital sign changes, physical decline in residents' condition. Guidelines included: observe/assess resident to determine status, notify attending physician as appropriate, carry out new orders, monitor resident for response. Documentation directives included: date and time of assessment and any interventions provided, date and time physician notified and if orders are received, observation and assessment of resident, to include response to intervention until the problem resolves.

Based on observation, clinical record review, resident, staff and a physician interview the facility failed to assure one resident remained free from a significant medication error, (Resident #1) The facility identified a census of 85 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 4/1/22 documented Resident #1 was admitted to the facility on [DATE] from an acute care hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented the resident required scheduled and as needed (PRN) pain medication related to frequent pain rated at a 5 on a scale of 0-10 with 10 having been the worst. A Care Plan with a goal initiated 3/29/22 documented the resident with pain related to the use of a [MEDICATION(S)] patch. On 3/30/22 the [MEDICATION(S)] patch had been placed on hold per family request. The interventions included the following as dated: a. Evaluate the effectiveness of pain interventions. Staff reviewed for compliance, alleviation of symptoms, dosing schedules and my satisfaction with results dated 4/29/22. According to Hospital Admission Records dated 3/29/22 at 2:08 p.m. the resident had been admitted to the facility with cancer associated pain related to a malignant neoplasm with mets to her lungs and end stand renal disease. The resident stood 5/6 tall and weighted 119 pounds. The [MEDICATION(S)] patch ended on 3/29/22 with a replacement scheduled on 3/30/22. According to a Medication Administration Audit Report form dated 3/24/22 thru 3/30/22 staff administered a [MEDICATION(S)] patch every 72 hours 12/mcg/hr (micrograms per hour). The instructions directed staff to have applied the patch transdermally every three (3) days for pain with the previous patch removed per schedule. The report indicated the patch as placed 3/30/22 at 8:17 a.m. The resident's medical record failed to document removal of a [MEDICATION(S)] patch already placed on the resident prior to admission. A Progress Notes entry dated 3/29/22 at 12:56 p.m. documented the following: What relieved the resident's pain: [MEDICATION(S)] patch. Scheduled pain regimen: Yes, [MEDICATION(S)] patch 72 Hour 12 MCG/HR| per one(|1) patch||transdermally| 1 time a day every 3 day(s). A Progress Notes entry dated 3/30/22 at 8:30 p.m. documented the following: Note Text: called to room per family as resident response had been lethargic, verbal response delayed and mental status altered, orientated to name only. Resident color of skin jaundice. Vital signs within normal limits. Impact team notified of vital signs and resident change in status form completed. Resident transported to hospital per ambulance. During an interview on 9/22/22 at 5:26 p.m. the resident's family member confirmed he was in the emergency room with the resident and observed the 2 [MEDICATION(S)] patches on her person and removed in front of him. The family member had met her at [CONDITION(S)] earlier that day and she indicated she felt weird. He dropped her off after [CONDITION(S)] and when he returned later in the day she sat positioned hunched over like a limp noodle. The family member called the nurse in and said you need to check her blood sugar. The nurses said she needed to go to the emergency room . At that point all five nurses present left the resident's room and left him to hold up his family member and no nurse ever returned to the room. When the ambulance crew arrived had been the next time any medical personal entered the resident's room. The resident arrived in the emergency room and the physician asked can you tell me why she had 2 [MEDICATION(S)] patches on because she should only have 1 patch and as soon as the physician removed the patch the resident began to perk up. A History and Physical form from the hospital dated 3/30/22 at 9:33 p.m. documented the resident presented in the emergency room somnolent but aroused easily with verbal stimuli and the hospital staff found 2 [MEDICATION(S)] patches on the resident's body. On 9/22/22 at 5:16 P.M. an emergency room (ER) staff member who cared for Resident #1 at the hospital confirmed when the resident arrived at hospital in ER noted two [MEDICATION(S)] patches on Resident #1. One was dated 3/27/22, placed at her prior hospitalization prior to admission to the nursing home and one dated 3/30/22 which would have been placed by the nursing home staff. According to https://apm.amegrops.com: The group documented a significant amount of [MEDICATION(S)] remained in a patch after a 3 day use described as between 0.7 mg and 1.22 mg of [MEDICATION(S)] left on a 2.5 mg patch. According to the National Library of Medicine at pubmed.ncbi.nlm.nih.gov: The group documented a sufficient amount of [MEDICATION(S)] available for abuse and misuse after 3 days of a therapeutic usage on a resident as between 0.7 mg and 1.22 mg of [MEDICATION(S)] left on a 2.5 mg patch. According to an email dated 10/13/22 at 10:16 a.m., a Physician documented with an initial application of a [MEDICATION(S)] patch (with no recent use of a [MEDICATION(S)] patch), onset peak effect occurred approximately 20-72 hours. After use of 2 sequential patches (two sequential, 72 hour applications), the concentration of the drug in the bloodstream had been considered stable/constant. Patient specific factors such as renal/hepatic function, age, medical commorbidities, interaction with concurrent medications, etc . can alter the absorption, metabolism/clearance (removal of the drug from or accumulation of the drug in the body) and effects of the [MEDICATION(S)]. Neurologic side effects of [MEDICATION(S)] included sedation/lethargy/confusion/drowsiness/fatigue and change in mental status. The Physician confirmed [MEDICATION(S)] remained in the patches after used on the body for 3 days.

Based on observation, clinical record review and staff interviews, the facility failed to develop interventions to prevent the development of a pressure ulcer for 1 of 4 residents reviewed (Resident #2). The onsite observation on 9/12/17 showed Resident #2 with a Stage III pressure injury on the resident's mid-spine/mid back. The only documentation the facility could provide regarding the area on the resident's mid back was from an evaluation dated 7/25/17 which documented a weekly skin assessment and noted a red and not open and on the vertebrae (upper middle) with [MEDICATION NAME] treatment applied. Record review revealed Staff A discontinued assessments of the area on 8/8/17 and the resident's record lacked any further assessment until 9/12/17. Staff D's written statement and interview revealed she was aware of the open area for August and September (2017) and was not concerned enough to notify anyone; and the treatment records revealed no change in treatment during this time (until 9/12/17). Interview with the DON revealed she would expect staff to report an open area on bony prominence. The facility reported a census of 82 residents. Findings include: Resident #2 had a Minimum Data Set (MDS) assessment with a reference date of 6/22/17. The MDS identified the resident with severely impaired memory and cognition. The MDS indicated Resident #2 required extensive assistance of two or more staff persons with bed mobility, transfer, dressing, toilet use, personal hygiene and total dependence for bathing. The MDS identified the resident had no impairment in bilateral upper extremity and lower range of motion, and used a wheelchair for mobility. The resident's [DIAGNOSES REDACTED]. The MDS indicated the resident experienced a weight loss of 5% or more in the last month or 10% or more in the last 6 months, not on a physician-prescribed weight loss regimen. The MDS further indicated the resident assessed as not at risk of developing pressure ulcers, and had no unhealed pressure ulcers. The MDS identified the following skin and ulcer treatments utilized: pressure reducing device for chair, and pressure reducing device for bed. (The MDS classified the following Stages of Pressure Ulcers: Stage l-An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: Skin temperatures (warmth or coldness); Tissue consistency (firm or boggy); Sensation (pain, itching); and/or A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. Stage ll-Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage lll- Full thickness tissue loss. Subcutaneous fat may be visible but the bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage lV-Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable-Slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar.) A Braden Scale for Prediction of Pressure Sore Risk dated as completed 6/22/2017 documented the residents score 18. A score of 15-18 indicated the resident at risk for pressure sore development. A physician notification form dated 4/14/17 ordered an Occupational Therapy (OT) referral, treat and evaluate for wheelchair positioning for pressure reduction to spine, apply [MEDICATION NAME] foam dressing every other day to spine to prevent pressure. A document titled Occupational Therapy OT Evaluation and Plan of Treatment dated as electronically signed 4/28/17 for the certification period 4/21/17-5/21/17 identified the reason for the referral as proper positioning for wheelchair. Evaluation of the current seating system identified [MEDICATION NAME] spine kyphosis-fixed and noted the resident demonstrated redness at [MEDICATION NAME] spine due to kyphosis. The document summarized the resident at risk of skin breakdown with poor hip alignment and posterior pelvic tilt. Custom modification and adjustments implemented, Comfort Company Element Back applied on 4/21/17 noted increased fit and pressure relief with customization to kyphosis to relieve pressure at bony prominences. A Care Plan with an onset date of 3/14/17, identified a focus area of at risk for pressure ulcers and other skin impairment due to immobility and incontinence related to dementia with a goal, dated initiated on 3/14/17 and updated on 7/13/17 that the resident would have no new skin impairment. The approaches directed staff to notify the primary care provider of any new or worsening skin issues, observe skin daily with cares and complete treatments as ordered. Record review of a Non-Pressure Skin Condition Report revealed an area on Resident #2's mid back healed on 3/21/17. Observations revealed the following: a. On 9/12/17 at 9:10 a.m. Resident #2 observed in room, seated in wheelchair. Resident #2 transferred from bed to wheelchair via Hoyer (mechanical) lift by Staff B, CNA (Certified Nursing Assistant) and Staff C, CNA. Pressure relieving positioning cushion noted in wheelchair with comfort back, and pressure reduction mattress on bed. Observed the Residents turned side to side in bed. b. On 9/12/17 at 9:47 a.m., the Assistant Director of Nursing (ADON) removed dressing and exposed area on the residents mid back. At this time the ADON measured the area and identified as a Stage III pressure area. The ADON stated had not been made aware of nor had seen the area before today. The resident had an area on mid back covering bony prominence of kyphotic (humped) spine that measured 6.0 cm. by 5.3 cm., with an open area 4.2 by 2.2 cm. A scant amount of serosanguineous (red tinged) drainage was noted on the dressing when removed. The open area was observed as red granulation (new) tissue with a white fibrous center. The area surrounding wound bed was noted as dark purple with yellow slough (dead tissue) at border of the open wound. A Progress Notes dated 9/12/17 written by the ADON identified the onset date of the pressure injury was 9/12/17. The progress note revealed Resident #2 had experienced pain related to the pressure injury. The resident showed non-verbal signs of pain at the location of the pressure injury. Review of a document titled Injury-204, dated 9/12/2017 at 10:19 a.m. revealed the Assistant Director of Nursing (ADON) documented area reported, and assessed. The assessment revealed the following wound measurement as follows: Complete wound measurement is 6.0 x 5.3 cm to mid-spine, open area to middle of the wound measured 4.2 x 2.2 cm, unable to measure depth, 65% of wound described as granulation tissue, some [MEDICATION NAME] (outer layer of skin) tissue, and scant amount of bloody drainage. The wound appeared moist, surrounding tissue dark purple color. Area staged as a Stage III pressure area. The only documentation the facility could provide regarding the area on the resident's mid back was a form labeled Nursing: Skin Evaluation: Non-Pressure dated 7/25/17 which documented a weekly skin assessment and noted a red and not open area on the vertebrae (upper mid) and [MEDICATION NAME] applied. A Discontinue Order created by Staff A, Licensed Practical Nurse (LPN) discontinued the weekly skin evaluation on 8/8/17 and identified the area had healed. The August 2017 and September 2017 treatment administration record (TAR) showed a [MEDICATION NAME] border (dressing) to red areas on spine and [MEDICATION NAME] foam adhesive(dressing) was signed as applied to open area on the resident's mid back every 3 days which was started 5/2/17. Staff documented they continued treatment of [REDACTED]. September 2017 ( 9/2/17, 9/5/17, 9/8/17 and on 9/11/17). The TAR directed on 7/25/17 for staff to complete a non-pressure skin evaluation for mid back open area every Tuesday, with a discontinue date of 8/8/17. Review of the clinical record revealed the facility failed to document any further assessments or any further observations of the area on the resident's mid back with change of dressing after 8/8/17 (until identified as Stage III on 9/12/17). A document tilted NSG: Pressure Injury Evaluation-V3, identified the resident experienced a pressure injury with an onset date of 9/12/17. The pressure injury described as pressure, mid-spine. Length: 6.0 cm, width: 5.3 cm, Stage III. A scant amount of serosanguineous drainage, injury bed pink/red granulation tissue, with dark purple surrounding tissue. Identified area as a new area, with treatment started. Physician, dietary, and family notified. In an interview on 9/12/17 at 10:30 a.m. the Director of Nursing (DON) stated a low air loss pressure relieving air mattress had now been requested for the bed, and the provider had been notified and a new treatment had been ordered. Confirmed area is a pressure area, concurred with stage III assessment. Staff A's witness statement dated 9/12/17 revealed the area on Resident #2's spine had healed on 8/8/17 and that's why the weekly assessments were discontinued. Staff A documented [MEDICATION NAME] was continued as a preventive measure. ( The TAR showed the [MEDICATION NAME] continued for August 2017 and September 2017.) In an interview on 7/6/17 at 12:40 p.m. Staff D, LPN reviewed August 2017 and September 2017 TAR and confirmed had routinely changed dressing, most recently 9/5/17 and 9/11/17. Staff D confirmed area had been open when observed throughout August and September 2017. Staff D described the area as observed today, as on open pressure wound and confirmed expectation to report an open area on bony prominence to DON, however had not reported as assumed DON aware as had been open when oriented in May 2017. Staff D's written statement dated 9/12/17 on the witness statement revealed on 9/5/17 and 9/11/17 revealed she had changed Resident #2's dressing on the resident's back. Staff D noted she would have an aide assist her to get the resident in bed. Staff D wrote a description of the area as follows: the area was open, a white center and it drains off and on; and the area on the outside was red. Staff D documented the wound did not appear to be getting worse or had a lot of drainage. Staff D documented she thought the [MEDICATION NAME] was just to protect the wound and she was not concerned to the point to notify anyone. In an interview on 9/12/17 at 2:10 p.m. Staff C, CNA confirmed frequently cared for the resident. Stated had observed the area to be open for at least two months. The facility received an order to change treatment on 9/12/17 to Santal and cover with normal saline gauze and dry gauze dressing daily. Further interview on 9/12/17 at 11:45 a.m. the DON stated had not been made aware that an open area on a bony spine had been identified, confirmed would expect staff to report an open area on bony prominence.

Based on clinical record review, observation, and interviews, the facility failed to provide adequate supervision to protect against hazards for one (1) of four (4) residents at risk for falls (Resident #1). The facility reported a census of 83 residents. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE], Resident #1 had modified independence with daily decision making and no long or short term memory impairment. The resident required limited assistance of one staff to transfer from one surface to another, ambulate, and to dress. The MDS revealed the resident had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Fall Risk assessment dated [DATE] revealed Resident #1 had a high fall risk. The initial, temporary Care Plan directed staff to assist Resident #1 with transfers and ambulation with the use of two staff and a gait belt, walker and wheel chair. The care plan indicated the resident sustained [REDACTED]. Interventions were added on [DATE] to included: check approximately every two hours and as needed, keep door open and may get details mixed up due to dementia. On [DATE] the resident sustained [REDACTED]. The Nurse's Notes dated [DATE] revealed Resident #1 admitted for palliative care with [DIAGNOSES REDACTED]. The resident had orders for physical and occupational therapy, answered some questions appropriately, poor historian and had an indwelling Foley catheter. The Nurse's Notes [DATE], staff found the resident next to the bed with a skin tear that measured 6 cm (centimeters) by 4 cm. Staff applied treatment and dressing to the wound. Incident Report dated [DATE] revealed staff found Resident #1 lying next to the bed at 3:30 a.m The resident sustained [REDACTED]. Staff dressed the wound and indicated they added a pressure bed alarm. The 200 Wing Siderail and Alarm Checklist revealed Resident #1 had a pressure alarm and tab alarm in bed on [DATE]. The Incident Report dated [DATE] revealed staff found Resident #1 at 1:30 a.m. lying face down on the floor between the bed and chair, noted bleeding to the left side of his/her face and right hand. Staff transferred the resident to the emergency room . Added [DATE] - to emergency room . On [DATE] - bed in lowest positron when in bed, move furniture away from bed, room move closer to desk, bolster mattress, discontinue air loss mattress. The Nurse's Notes dated [DATE] at 2:00 a.m., revealed staff found the resident lying face down on the floor between the bed and chair, bleeding noted to right hand and left side of face and bilateral shoulders. The resident stated he/she rolled out of bed. Staff notified the physician and sent the resident to the emergency room . At 5:00 a.m. the Notes indicated the resident admitted to the Intensive Care Unit for a head bleed. A review of the Hospital Records included: admission on [DATE], discharged on [DATE]. The emergency room (ER) report revealed the resident had extensive areas of ecchymosis scattered over the body, skin tears noted on some extremities. The resident had facial laceration on the left orbital rim into the eyebrow noted. The resident had a lower lip laceration and soft tissue swelling noted on the forehead. The assessment revealed traumatic intraparenchymal hemorrhage, without loss of consciousness, lip laceration, face lacerations and the resident would be admitted . The computed tomography (CT) examination of the resident's head on [DATE] revealed Hyperattenuation (blood buildup) left frontal lobe likely indicating a small amount of hemorrhage. The Hospital Discharge Summary revealed the resident had recently discharged from the hospital after being admitted for multiple skin ulcers/cellulitis; and then sent to skilled care the nursing home. The resident fell from the bed on [DATE] and hit his/her head, brought to the hospital where he/she was found to have a left frontal lobe hemorrhage. The resident had been admitted to neurosurgical service for intracranial bleed management. The resident's INR (international normalized ration) reversed with the patient and vitamin K, acute kidney injury, laceration on lower lip sutured in the emergency room , seen and followed by neurosurgery, no surgical intervention, patient transferred to hospitalist services. The resident had an abnormal urinalysis and antibiotics were administered. The principal [DIAGNOSES REDACTED]. The resident would return to the skilled nursing facility. On [DATE], the care plan directed staff to keep all furniture away from head of bed. The resident had a low loss air mattress discontinued on [DATE]. On [DATE] the Care Plan added a bolster mattress to the bed, move closer to the nurse's station, mat on floor on both sides of the bed and bed in lowest position. On [DATE] at 11:00 a.m. staff spoke to the resident's family member and discussed removing the air mattress and changing it to a bolster mattress for safety. Family agreed to move the resident closer to the nurse's station upon return from the hospital. Staff also moved the chair in the room away from the bed. physician progress notes [REDACTED]. Follow up regarding increased respiratory problems with low oxygen saturation and congestion. Started on Doxycycline yesterday, and give three doses of Lasix for three days due to bilateral pleural effusions probable pneumonia. Lung sounds coarse throughout. Cautiously treating pneumonia due to chronic kidney disease, eats and drinks poorly. Staff discussed hospice services with family. On [DATE], staff noted the resident had diminished lung sounds bilateral bases, Oxygen saturation at 95% with oxygen, unable to take temperature due to resident breathing with mouth wide open. Observation on [DATE] at 9:30 a.m. revealed Resident #1 in a low bed with a concave mattress and a blue mat beside the bed. The resident, on his/her back, appeared calm and had oxygen per nasal cannula and a Foley catheter. The resident had eyes open but failed to respond to questions. The DON (Director of Nursing) indicated the resident's family currently considered hospice. On [DATE] the Care Plan added: bed up against the wall. On [DATE] at 9:20 a.m., the Notes indicated the resident ate very little with assistance, took medication with applesauce and staff re positioned every two hours. At 8:20 p.m. the resident passed away, found unresponsive by CNA. During an interview on [DATE] at 3 p.m., the DON revealed on [DATE], Resident #1 returned from the hospital and they were told the resident had a small bleed. The resident also had facial laceration. After the fall, they discontinued the alarms. The resident failed to progress in therapy and had dementia. After the resident fell , the DON measured the bed frame at 28 inches above the floor. At the time of the fall, staff reported that Resident #1 had only the pressure alarm on the bed which failed to sound. Staff failed to apply the TAB alarm. On [DATE] at 3:35 p.m. the surveyor measured bed height with the DON and observed: Bed frame to floor measured 12 inches if in the lowest position. A regular mattress measured approximately 6 inches and an air loss mattress measured 8 inches. During an interview on [DATE] at 3:10 p.m., the Nurse Practitioner revealed the cause of death certificate had not yet been completed, and Resident #1 had failure to thrive along with multiple diagnoses. The fall with the head bleed altered the resident's mental status. The Nurse Practitioner indicated he/she could not verify that the fall on [DATE] led to the resident's death on [DATE]. The facility investigation included a statement from witness, Staff A, CNA (Certified Nurse's Aide) by phone and documented by the DON (Director of Nursing). Staff A indicated he/she changed the resident's incontinent brief at approximately 1 o'clock a.m. on [DATE]. Staff A revealed the resident had a bed alarm on when he/she left the resident. Twenty minutes later the resident yelled and Staff A found the resident laying on the floor. The resident indicated he/she rolled out of bed and hit the chair next to the bed. Staff A indicated the bed alarm failed to sound but worked when he/she checked it after the fall. The bed measured approximately 2 feet from the bed. Staff A could not be reached for an in person interview during the investigation. During an interview on [DATE] at 2:10 p.m., Staff B, LPN (Licensed Practical Nurse) indicated he/she worked at the time of Resident #1's fall on [DATE]. The resident had an air mattress with a pressure alarm over it, the resident failed to have a TAB alarm at the time of the fall. When the resident fell from the bed, the pressure alarm failed to sound but knew the alarm functioned prior to the fall when checked earlier in the day. After the resident fell , Staff B observed the bed failed to be in the lowest position, but at regular height of approximately 29 inches. Staff A told Staff B that he/she changed the resident prior to the fall and failed to lower the bed, though he/she never reported why. When Staff B checked the pressure alarm, it failed to function the first time but did function with the second check. The resident reported rolling out of bed. Staff B worked the evening the resident passed away. The resident had been declining, the resident remained in bed and refused supper. At 8:20 p.m. staff found the resident passed away and staff notified family. During an interview on [DATE] at 3:00 p.m., Staff C, RN revealed on [DATE], Staff added a TAB and pressure alarm to Resident #1's bed. The resident had no chair alarms. On [DATE] staff discontinued the TAB alarm and on [DATE] they discontinued all alarms. When the resident fell from the bed on [DATE], he/she should have had a pressure alarm and a TAB alarm.

Based on observation, staff interviews and record review, the facility failed to ensure the resident environment remains as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents when they failed to ensure staff used appropriate caution when opening the door to the locked dementia unit (Resident #3, #4). The facility reported a census of 61 residents and 19 of the 61 residents lived in the secured dementia unit. The sample consisted of 4 residents. Findings include: 1. Resident #4 had a MDS (Minimum Data Set) with a reference date of 7/9/13 which identified the resident had a memory impairment and severe cognitive impairment. The MDS reflected the resident transferred and walked independently. The resident received no routine pain medication and denied any pain. Interdisciplinary Progress Notes dated 7/10/13 noted the resident required set up, supervision or assistance of one person with all cares due to dementia. Resident transferred and walked independently on the CCDI (Chronically Confused Dementia Unit). Frequently incontinent of bladder. Resident #4 had a Minimum Data Set (MDS) assessment, with a reference date of 10/31/13. The assessment noted Resident #4 required extensive assistance with bed mobility, transfers, walking, dressing, toilet use and personal hygiene. The resident received scheduled pain medication and rated his/her pain at a 5 on a scale from 1 to 10. The resident had active [DIAGNOSES REDACTED]. Nurse's Notes dated 9/19/13 at 10:00 p.m. reflected the staff opened the door to the unit at shift change and the resident was standing behind the door. The door hit the resident and the resident fell to the floor. The right side of the resident ' s body hit the floor. The resident hit head on ground. Also landed on right shoulder, hip and knee. Blue bruise and swelling to the right brow. Bruise and pain to the right knee. No bruising noted to right hip but voiced complaints with adduction. No weight bearing to right leg when standing. An order was received from the physician to send the resident to the emergency room . Nurse's Notes dated 9/20/13 at 1:20 a.m. reflected the facility received a telephone call from the hospital emergency room nurse. The resident would be returning to the facility. The nurse informed the facility all of the x-rays were negative (for fractures). Nurse's Notes dated 9/20/13 at 2:30 a.m. resident returned to facility. Resident very hesitant to put any weight on right leg. Right knee bruised and painful to touch. Nurse's Notes dated 9/20/13 at 6:45 p.m. revealed a resident complained of pain with repositioning/transfers. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Nurse's Notes dated 9/21/13 at 6:30 p.m. reflected the resident denied any pain (but) noted some facial grimacing during repositioning. Nurse's Notes dated 9/22/13 at 10:45 a.m. reflected the staff transferred the resident to a wheelchair with assistance of two (staff) and gait belt and resident had large emesis immediately after the transfer. Resident complained of pain with transfer, but unable to specify location of pain. Staff notified the physician. Nurse's Notes dated 9/24/13 at 3:10 p.m. reflected Tylenol given for right knee pain. Resident grimacing and moaning during the transfers. Nurse's Notes dated 9/24/13 at 11:10 p.m. reflected Tylenol given for right leg/knee pain. Nurse's Notes dated 9/24/13 at 12:20 a.m. revealed the Resident still grimacing and moaning in pain. A Physician's Notification dated 9/25/13 informed the physician the resident fell on [DATE], still having a lot of pain to right leg/knee; x-rays were negative when sent to the emergency room . Tylenol failed to relieve this resident's pain. The physician then ordered Tramadol 50 mg every 8 hours routinely for one month. Nurse's Notes dated 9/26/13 at 11:30 a.m. resident seen by physician today at facility. The physician gave a new order to obtain blood work (laboratory tests). Nurse's Notes dated 9/27/13 at 1:15 p.m. reflected the resident moaning and crying out with morning cares. Tramadol given as ordered. Yellow bruise at knee cap and bruise to right forehead fading. Interdisciplinary Progress Notes dated 9/26/13 noted resident had a fall on 9/19/13 and required assistance of one to two persons with transfers and walking, and used a wheelchair for mobility. Resident reported pain at a 7, on a 1 to 10 scale. Nurse's Notes dated 10/11/13 at 10:50 a.m. reflected the resident continued to complain of right leg discomfort, physician notified. A Physician's Notification dated 10/11/13 informed the physician the resident had a fall on 9/19/13, complained of right leg discomfort, was sent to the emergency room and returned with care instructions for the right knee. Resident continued to complain of discomfort and would not bear weight to the right leg. Physical therapy believed the pain was from the resident's hip area when they worked with him/her. A physician's orders [REDACTED]. Nurse's Notes dated 10/11/13, (no time given), x-ray report received from Bio Tech X-Ray, acute femoral neck fracture (hip) without displacement. The note reflected the staff sent the x-ray report to the physician. Nurse's Notes dated 10/14/13 at 10:40 a.m. return call from the physician with a new order to send the resident to the hospital for a direct admission. Nurse's Notes dated 10/17/13 at 1:12 p.m. reflected the resident returned to the nursing home. A hospital consultation report dated 10/15/13 included this resident fell and sustained a right hip fracture. The resident walked with a fairly normal gait. The right leg flexed at the knee. The plan included a right total hip joint replacement. A Resident assessment dated [DATE] listed readmission to the nursing home from the hospital after repair of the right hip fracture. The skin condition noted eight bruises and a 19 cm (centimeter) incision on the right hip. A Pain Evaluation dated 10/17/13 assessed the resident with acute, internal pain treated with an oral pain medication, Hydrocodone (narcotic analgesic) 5/325 every four hours as needed for pain. Observation on 11/18/13 at 11:30 a.m. revealed the double doors leading into the locked dementia unit contained two small windows, each with a valance. This surveyor standing 5 foot 7 inches tall could not see all areas behind the doors. Observation revealed two mirrors one on each side inside the locked unit. By looking through the small windows and utilizing the mirrors, one could see behind the locked doors. The key pad to unlock the doors was located along the hall wall approximately four feet from the door. Observation on 11/19/13 at 11:28 a.m. revealed a resident in the locked unit stood in a dark corner by the exit door, out of visual view from the small windows only. At this time, charge nurse, Staff H stated the resident liked to stand there or on the other side and staff could not see him/her from the windows. She stated three residents in the unit liked to stand in the corners by the exit door. Photographs obtained of the unit doors. When interviewed on 11/19/13 at 4:30 p.m. a certified nursing assistant, Staff A stated she was coming to work in the locked unit. Staff A stated she was 5 foot 1 inches tall. When she opened the unit door, the door swung inward, she heard people yelling and then she saw Resident #4 stumble and fell to the floor. Staff A stated prior to opening the locked door; she had entered the code into the key pad on the wall to unlock the door. She then stood on her toes to look in the window, but she could barely see in. She was not aware of the mirrors at that time. She stated normally the residents were in bed when she reported to work at 10:00 p.m. so she had just expected them to be in bed. When interviewed on 11/19/13 at 12:50 p.m. a certified nursing assistant, Staff B stated she was working in the locked unit at the time Resident #4 fell . She stated that evening Resident #4 was not sleeping well and the resident was up out of bed, pacing up and down the hall. She had seen the resident walk towards the exit doors, when the resident reached the exit door he/she turned around and then someone opened the door, normal speed, (not slow, not fast), and hit the resident. The resident stumbled and fell . The resident fell pretty hard. The resident's head hit the floor and bounced. Staff A then entered the unit and stated she had not seen Resident #4 behind the door due to she was so short. Resident #4 was crying and moaning. They could tell the resident was in pain. Staff B stated in the past, she had seen residents bumped by the door when staff entered the unit. Staff B stated she never received formal instruction about the use of the mirrors. When interviewed on 11/19/13 at 12:28 p.m. an agency aide, Staff C stated she was sent to work the afternoon shift at this facility the day Resident #4 fell . She was in the hall when the night shift aide failed to look through the window prior to opening the door leading into the unit. The door hit Resident #4, the resident stumbled and fell . Staff C stated when she came to work at this facility; she was not informed of the necessity to look at the mirrors prior to opening the door. When interviewed on 11/19/13 at 2:25 p.m. a licensed practical nurse, Staff D stated she was working when Resident #4 fell . She stated that evening Resident #4 kept getting out of his/her bed, so they put the resident's shoes on and let the resident pace in the hallway. Resident #4 was standing by the exit door when it opened. Staff A opened the door at a normal speed, (not real fast and not slow), which caused the resident to fall. The resident stumbled and then fell hard. Staff D stated she did not know the mirrors were there. When she began working at the facility no one informed her about the mirrors. She knew right away the resident was in pain. Some residents liked to stand behind the doors and she knew of residents being bumped by the door when staff entered the unit. When interviewed on 11/19/13 at 12:05 p.m. a certified nursing assistant, Staff E stated she had to get on her tip toes to see through the window of the entrance to the locked unit, to make sure no one was behind the door. Some residents like to stand behind the doors. When interviewed on 11/20/13 at 8:10 a.m. a charge nurse, Staff F stated she had known staff to bump residents with the door when they entered the locked unit. When interviewed on 11/19/13 at 3:30 p.m. the Maintenance Supervisor stated he takes newly hired staff members on an environmental tour of the facility upon hire. He tells new hires they need to look through the windows of the unit and to open the door slowly. He stated he did not inform newly hired employees about the mirrors in the unit, or of the need to use the mirrors to ensure residents were not standing behind the doors. The plan of care dated 7/23/13 and 11/12/13 identified Resident #4 ' s problems included dementia, hearing loss, self-care deficit, Alzheimer's Dementia, a lack of safety awareness, a history of hip fracture and post-traumatic stress disorder. The goals included no injury from falls. The approaches included living on the locked CCDI unit, the resident walked independently, to utilize an abduction pillow while in bed and to elevate right leg at all times. 2. An MDS assessment tool with a reference date of 8/27/13 listed medical [DIAGNOSES REDACTED].#3. The resident scored 2 out of 15 on the cognitive scoring test, revealing cognitive impairment. The resident required extensive assistance with dressing, toilet use and personal hygiene. The resident transferred and walked independently. The resident's plan of care dated 6/20/13 and 9/10/13 identified this resident's problems included dementia, osteoarthritis, and risk for injury related to cognitive impairments and use of antipsychotic medications. When interviewed on 11/20/13 at 12:15 p.m. a certified nursing assistant, Staff G stated she was not aware of the mirrors. She stated one time she entered the locked unit, she had not seen a resident on the other side of the doors, and the door hit Resident #3 on the head when she opened the door. The resident had a swollen, red area and the resident told her it hurt. Resident #3 liked to stand behind the doors. At the time of that incident the nurse told her she needed to use the mirrors before opening the door. An Incident/Accident/Unusual Occurrences Form dated 3/20/13 noted C.N.A. was opening the CCDI unit door from other side and didn't see resident by door. Resident bumped head on door. Ice pack applied to forehead. Swelling to right forehead initially then subsided after ice applied. A Psychiatric Progress Note dated 2/28/13 documented when awake, the resident wandered. The resident had no coherent language and had impaired memory, insight and judgment. A Physician Notification report dated 3/20/13 informed the physician staff opened doors to CCDI unit from the other side, resident standing behind doorway, staff did not see resident and the resident bumped head on doorway. The resident had slight swelling to the right forehead. The staff applied an ice pack until the swelling subsided.

Based on observation, record review and staff, resident and family interviews, the facility failed to assess the resident ' s skin condition for 2 of 4 residents reviewed with ostomy sites (Residents #1, #2). The facility reported a census of 62 residents. Findings include: 1. Resident #2 had a Minimum Data Set (MDS) assessment with a reference date of 5/29/12, which documented Resident #2 had an admitted to the facility of 3/22/12. The MDS assessment documented the resident had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had severely impaired vision, did not wear glasses and required extensive assistance for bed mobility, transfers and toilet use. The MDS assessment documented the resident had an ostomy for bowel elimination and received skin treatments for a surgical wound. The Care Plan dated 5/27/12, informed staff the resident required the assistance of staff to empty the [MEDICAL CONDITION] bag and needed help changing the collection bag. The Care Plan informed staff the resident had a potential for impaired skin integrity and directed the staff to evaluate the resident's skin weekly with the resident's bath/shower. The physician orders [REDACTED]. On 5/17/12, the physician directed staff to change the resident's [MEDICAL CONDITION] bag twice weekly and as needed. On 5/24/12, the physician ordered staff to change the right stump dressing daily and cover with a dressing and change the [MEDICAL CONDITION] bag twice weekly and as needed. The Nurse ' s Notes dated 5/29/12 at 6:05 p.m., revealed a facility nurse called the resident's physician to report an increase in the resident ' s confusion, unable to feed self and attempted to eat her/his ring. The Physician directed staff to send the resident to the local emergency room . Review of the Emergency Department Chart dated 5/29/12, revealed the resident had skin breakdown noted around the stoma, breakdown noted to bilateral groin areas and genital areas and a pinpoint open area on the scrotum. Upon physical exam, the ostomy bag was noted to be leaking and the skin inferior to the bag extending to the genitals red and inflamed. A History and Physical from a local hospital dated 5/29/12 revealed the resident had an admission to the hospital on [DATE] due to cellulites of the abdominal wall around the [MEDICAL CONDITION] site. Review of a Discharge Instruction Report dated 6/5/12, revealed the resident would transfer from the hospital with a primary [DIAGNOSES REDACTED]. The Nurse ' s Notes revealed the resident returned from the hospital on [DATE] at 2:15 p.m. The Resident Assessment-Data Collection on 6/5/2012 at 2:15 p.m. indicated the resident had no problems with skin condition in the abdomen or perineal areas. The assessment did not identify the stoma located on the abdomen. The Nurse ' s Notes dated 6/5/12 at 3:00 p.m. indicated the admitting nurse could not see the stoma or the site of the cellulites, due to the bag being in place. The facility staff failed to have a non-pressure skin condition report form that identified redness or skin issues on the resident's abdominal wall area, surrounding the stoma The Nurse ' s notes from 6/6/12-6/14/12, did not document staff assess the site of the cellulites. The staff documented the resident continued with an antibiotic for the cellulites. Review of the June 2012 Treatment Record, directed staff to change the [MEDICAL CONDITION] pouch as needed. The resident did not have any documented [MEDICAL CONDITION] pouch changes from 6/5-6/13/12. Continued review of the June 2012 Medication and Treatment records failed to address the cellulites to the resident's stoma site, failed to direct staff to monitor the cellulites site or the stoma and surrounding skin condition. Observation on 6/13/12 at 5:15 p.m., revealed Staff A Certified Nursing Assistant (CNA) performing peri care for the resident. Staff A cleansed the resident's abdominal area as the resident yelled out, "Oh it's sore around that bag". Observation revealed the ostomy bag intact to the resident's abdominal wall. On 6/14/12 at 3:00 p.m., the Assistant Director of Nurses (ADON) was interviewed and stated the staff failed to start a skin monitoring form for the cellulites area upon return to the facility on [DATE]. On 6/14/12 at 10:00 a.m., Staff B (Registered Nurse) was interviewed and revealed the resident had a transfer to a local emergency roiagnom on [DATE] on her shift. The nurse stated hospital staff called the facility to inquire about the skin breakdown around the stoma site. The nurse stated she did not know the resident had a skin issue around the ostomy but aware of the groin red. J Staff B stated the CNA ' s change the bag but did not report redness. On 6/14/2012 at 10:28 a.m., Staff C (Licensed Practical Nurse) was interviewed and stated yesterday the Certified Medical Assistant (CMA) had reported redness surrounding the stoma. Staff C reported she put powder around the stoma and the bag was changed. Staff C thought the redness could be from leaking feces and every once in a while will have redness surrounding the stoma. Staff C stated did not think the care to the ostomy was documented on the treatment record. Staff C stated the nurses change the [MEDICAL CONDITION] bags and wafers (what the bag attaches to) and etc. The CNA ' s empty the contents from the bags. On 6/14/2012 at 10:13 a.m. Staff D (CNA) was interviewed and stated the ostomy bag gets emptied every day and the bag changed at least every other day. Staff D stated the nurses perform the bag/wafer change. Staff D stated the CNA ' s only empty the contents from the bag. 2. The June 2012, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Review of the April, May and June 2012, Treatment Record did not indicate the resident had a [MEDICAL CONDITION] and failed to direct staff how to or to monitor resident when caring for the [MEDICAL CONDITION]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had severe cognitive impairment, required extensive assistance for bed mobility, dressing and personal hygiene needs and limited assistance transfers and toilet use. The MDS assessment did not identify the resident had an ostomy. On 6/13/12 at 1:30 p.m., the resident stated they had a [MEDICAL CONDITION] and reported he/she cared for the [MEDICAL CONDITION] them self. The Care Plan dated 4/2/12, directed staff to assist the resident with ostomy cares but failed to direct them of the type of care the resident required. The Nurse ' s Notes from admission on 4/2/12 to 6/14/12, did not mention the resident's [MEDICAL CONDITION]. On 6/14/2012 at 10:13 a.m. Staff D was interviewed and stated the resident cares for own [MEDICAL CONDITION] by emptying the bag and reinforces it. Staff D stated the resident still knows how to care for self but talks about " crazy " stuff. On 6/14/2012 at 10:28 a.m. Staff C was interviewed and stated the resident keeps supplies in a suit case and will let staff know if the bag comes loose or needs to be changed. Staff C stated the bags are only changed as needed and then changed on bath days by the nurse. Staff C identified the resident as disoriented to time and experienced confusion at times. On 6/14/2012 at 10:30 a.m., Staff E described the resident has very confused at times. Staff E stated the resident empties the [MEDICAL CONDITION] bag independently and the nurse ' s change the wafer. The CNA ' s will notice if the bag needs changed and the CNA ' s will change the bag but not the wafer. On 6/14/2012 at 11:50 a.m. the Assistant Director of Nursing (ADON) was interviewed and stated when the resident first arrived to the facility, a Skilled Nurse Check List document had ostomy care listed. When the resident had finished with the skilled nursing care, then the record revealed no further documentation could be found. The ADON stated the CNA ' s check the resident ' s skin during bath time and document on the bath sheets. The facility nurses rely on the CNA ' s to report issues.

Based on observation, record review and an interview with the wound clinic nurse, the facility failed to follow interventions as planned to promote healing and prevent a decline for one resident reviewed with a pressure sore. The facility census was 62 residents. ( Resident #4) Resident #4 had a risk of pressure ulcers and required extensive assistance by at least 2 staff persons with bed mobility and transfers. The resident developed an avoidable pressure sore on the coccyx area. The facility implemented a low air mattress for the bed and a pressure reducing cushion in the chair. Although the facility had implemented a low air mattress, the recommendations for the low air mattress were not followed. The recommendations directed the facility to limit layers between Resident #4 and the air mattress. Based on observation and review of the MDS (Minimum Data Set) assessment, the facility did not have a system in place to ensure the staff repositioned the resident frequently and routinely so pressure areas (boney prominences) were off loaded. Findings include: 1. Resident #4 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 1/27/2012. The assessment reflected that Resident #4 required extensive assistance with bed mobility and transfers with the assistance of at least 2 people. The assessment identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident to be at risk for developing a pressure ulcer and the facility had placed a pressure reducing device on the bed and in the chair. The assessment, however, reflected the facility did not have a turning and repositioning program. The assessment indicated the resident did not have pressure ulcers or arterial/venous ulcers. The annual MDS assessment with a reference date of 4/20/2012 indicated the resident to be at continued risk or pressure ulcers. The assessment identified the resident had 2 unstageable pressure sores due to coverage of slough and/or eschar. The resident had no arterial or venous ulcers present. The MDS indicated the largest pressure sore measured 2.5 centimeters (cm) by 1.5 cm, with no depth. The MDS indicated the resident required extensive assistance of two staff persons for bed mobility and transfers. A hospital Wound Outreach Consultation Record dated 11/7/11 indicated the resident had a problem with a right inner buttock ulcer. The area had been treated with Sensicare (protects and relieves chapped skin). The ARNP (Advanced Registered Nurse Practitioner) recommendation included a low loss air mattress with no undergarments and to limit the layers between the patient and air mattress. The Care Plan identified a problem on 8/11/2011 which identified a potential for impaired skin integrity related to impaired mobility and cognitive status. The Care Plan update dated 2/26/2012 identified a problem with an open area located on the coccyx and left buttock. The interventions directed staff to: a. Collaborate with hospice in providing treatment. b. Nutritional supplement. c. Low air-loss mattress. d. No brief on in bed. e. Use only paper Chux (incontinent pad) in bed. f. Lay me down after meals. A wound/skin healing record revealed the resident developed an open area to the coccyx with an initial onset date of 4/10/12. The record revealed the following assessments: a. On 4/10/12, the area measured 4.0 centimeter (cm) by 5.5 cm, superficial area but unstagable. The resident experienced pain (scale 4-6) related to the wound and the resident moaned. The left buttock had slight maceration present and a purple area which measured 1.5 cm by 1 cm. The right buttock had a purple area present which measured 1.5 by 1 cm. b. On 4/13/12, the coccyx area measured 1.2 cm by 0.8 cm by 0.2 cm area. The coccyx was not stageable and had serous exudate present. The area had white slough and black areas. The right buttock measured 1.5 by 0.4 cm and purple. The left buttock measured 2 cm by 1 cm and purple. The resident continued to experience pain with non verbal grimacing and moaning. c. On 4/20/2012 the coccyx measured 2.5 cm by 1.5 cm by 0.25 cm. The wound had yellow slough present. The left buttock had an area of 1.3 cm by 0.5 cm. The resident experienced no pain. The treatment record revealed on 4/20/2012, a new treatment was obtained. The order directed staff to apply Santyl ointment (wound debridement) each and cover with a dry gauze dressing. The facility began [MEDICATION NAME] (dietary supplement to promote healing) twice a day. d. On 4/27/12 the coccyx area measured 2.0 cm by 1.0 cm by 0.1 cm area. The left area measured 0.9 cm by 0.3 cm area. The coccyx had white slough present and still identified as not stageable. The resident experienced no pain. e. On 5/4/12 the coccyx measured 2.7 cm by 1.4 cm area, no depth indicated. The coccyx had a small amount of serous exudates present which had a slight odor. The surrounding skin had a white and pink color present. The resident had pain and tenderness when touched. f. On 5/11/12 the coccyx measured 2.3 by 1 cm. The ulcer had serous exudates present with a slight odor. The sound had slough present with maceration surrounding the wound. The record revealed no depth measured. The resident experienced no pain. Review of the record on 5/24/12, revealed no assessment documentation for the week of 5/13/12 through 5/19/12. On 5/23/2012 at 6:41 a.m., Staff M (Licensed Practical Nurse) was observed performing a treatment to the resident ' s coccyx. Staff M sprayed a 4 inch by 4 inch gauze square with wound cleanser and wiped in a scrubbing motion, back and forth, to cleanse the open area located on the coccyx. On 5/24/12 at 8:43 a.m., Staff N, LPN measured the open area on the resident ' s coccyx. The area measured 2.0 cm by 1.0 cm with a depth of 0.25 cm. (the area had no depth present within the past few weeks) At 1:05 p.m., observation revealed the resident in bed and lying on an alternating air mattress. The resident lay on top of what appeared to be numerous layers of linens. At that time, the surveyor requested Staff A, Director of nursing, DON to assess what the resident had been lying on. Staff A verified the resident laid on the top of two layers of a quilted bedspread, a cloth soaker pad, a top sheet, a bottom sheet and a pressure alarm. The resident wore sweat pants and an incontinent brief as well, and lay on his/her back in a supine position. At that time, Staff A exited the room making no changes. At 1:35 p.m., the resident remained on the layered bed on his/her back. At 2:02 p.m., the resident remained on his/her back on the layers over the air mattress. At 3:07 p.m., the resident remained on the bed with the layers and appeared to be attempting to sit up. At that time, the surveyor notified Staff F, Administrator who left to obtain the nursing staff assistance. At 3:15 p.m. or two hours and ten minutes later, Staff F, Administrator stated the resident had not been incontinent so everything had been all right. On 5/25/12 at 6:30 a.m., the resident laid in bed on his/her back on the low air-loss mattress. The resident wore an incontinent brief and had a pressure alarm, bottom sheet and cloth soaker pad on the low air-loss mattress. On 5/25/12 at 8:30 a.m., a nurse consultant from the wound clinic stated any layering over a low air- loss mattress would hinder the benefit of the mattress.

Based on observation, record review and staff interviews, the facility failed to plan for and direct the nursing care services to ensure residents needs are met to prevent pressure ulcers and provide wound care as ordered. The facility identified a census of 69 residents and 5 of the 69 residents had facility acquired pressure ulcers (Resident #1, #4, #11, #13). The sample consisted of 4 residents with pressure ulcers. Findings include: 1. Resident #11 had a Minimum Data Set (MDS) assessment with a reference date of 2/11/11. The MDS reflected Resident #11 had problems short and long-term memory, severe cognitive impairment, required extensive assistance with bed mobility, transfers, non-ambulatory, required total assistance with dressing, eating, toilet use, personal hygiene and bathing. This resident's active [DIAGNOSES REDACTED]. The assessment noted this resident was on a scheduled pain medication regimen. The assessment noted this resident's risk for pressure ulcers and noted had one or more unhealed pressure ulcers at the time of the assessment. The assessment noted a new Stage 2 (Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) pressure ulcer. The Skin and Ulcer treatments on the assessment included: pressure reducing device for bed and chair, ulcer care, application of nonsurgical dressings and ointments/medications. The resident received antipsychotic and antidepressant medications on a routine basis. The resident received Hospice Care. The CAT (Care Area Triggers) Worksheet dated 3/30/11, found with the MDS, noted the staff transferred this resident with a mechanical lift, the resident was on a check and change program and wore an adult incontinence product when up. The staff provided the resident with incontinent care and barrier after each incontinent episode. The CAT Worksheet for Pressure Ulcer dated 3/30/11 noted this resident had an existing pressure ulcer, needed special mattress/seat cushion to reduce/relieve pressure, and required staff assistance to move sufficiently to relieve pressure over any one site. The resident's [MEDICATION NAME] Risk Factors included immobility, alerted mental status, recent weight loss and incontinence. The Analysis of Findings noted this resident had a [DIAGNOSES REDACTED]. The Care Plan identified a problem on 10/5/2010 with actual impaired skin integrity in regards to Alzheimer ' s disease and decreased mobility. A problem on 3/18/2010 identified the resident required staff assistance with all activities of daily living. The intervention directed staff to reposition the resident frequently with the assistance of 2 people. The care plan identified a problem with frequent episodes of urinary incontinence and directed staff to check and change the resident before and after meals, at bedtime and as needed. A Physician's Nursing Home Visit dated 1/20/11 noted Resident #11 ' s history and recent skin issues. The physician noted the resident's skin issues as treated per the facility protocol. A Physician's Nursing Home Visit dated 3/17/111 noted the resident had a couple of small sores on the bottom area. The physician noted the resident received protein supplementation and received wound care per facility. The TAR (Treatment Administration Record) for March 2011 noted a physician's orders [REDACTED]. The physician's orders [REDACTED]. According to the nurse's documentation, the staff completed the treatment on 3/1/11, 3/3/33, 3/5/11, 3/7/11, 3/9/11, 3/12/11, 3/13/11, 3/15/11, 3/22/11, 3/24/11, and 3/27/11 and on 3/29/11. The staff failed to follow the physician's orders [REDACTED]. A Nurse's Notes dated 2/10/11 at 8:30 p.m. noted the resident had two open areas to the coccyx area. A Nurse's Notes dated 3/23/11 at 1:40 a.m. noted the Certified Nursing Assistant reported, and the nurse noted a new open area to the right side of this resident's scrotum measuring 1 centimeter (cm) by 1 cm. The nurse described the base of this wound as beefy red. The nurse also noted to the right outer thigh a red area which measured 5 cm by 0.3 cm. A Nurse's Note dated 3/29/11 noted an area to the coccyx which measured 1 cm by 1 cm with white/purple slough. A message sent to the physician dated, 2/10/11 noted two open areas on the coccyx. One area measured 0.4 cm by 0.3 cm and the second open area measured 0.3 cm by 0.2 cm. A Wound/skin healing record noted an open wound which measured 0.2 cm by 0.2 cm on 3/24/11 and increased in size to 1 cm by 1 cm on 3/29/11. The resident's Care Card found on the back of the resident's bedroom door instructed the staff to "Check and Change" under toileting and to use an adult brief when up. When interviewed on 4/12/11 at 2:20 p.m. the Director of Nursing stated the facility had no specific policies for check and change. Observation on 3/29/11 at 7:45 a.m. revealed Resident #11 up in a wheelchair. A Hospice employee asked a facility staff member to assist with placing a pillow under the resident's right arm. The staff assisted the resident to a more upright position by pulling the resident to the left and placing the pillow under the resident's right arm. Observations revealed no toileting or repositioning of this resident through the morning and through the remainder of the day shift. When interviewed on 3/29/11 at 2:50 p.m. the two nursing assistants assigned to care for this resident on the day shift on 3/29/11, Staff D and Staff E, verified they provided no position changes, no pressure relief and no toileting or changing of this resident's incontinent brief since they got the resident up and out of bed prior to 7:45 a.m. Observation on 3/29/11 at 2:53 p.m. revealed the second shift nursing staff, Staff K and Staff L took the resident in the wheelchair from the resident ' s bedroom to the shower room for a shower. The staff used the EZ lift and transferred the resident into a wheelchair and onto the shower chair. After removal of the resident ' s clothing, observation revealed a very thin resident. The staff then removed the resident's pants and urine soiled brief by pulling on the clothing and the brief. The staff used force to pull the brief and the clothing to remove these items as the resident sat on the shower chair. At this time the surveyor intervened to stop this shearing. The staff then placed a gait belt on the resident, the two staff members stood the resident while the Director of Nursing then pulled down the resident's pants and soiled brief. On 3/29/11 at 3:35 p.m. Staff K and Staff L transferred this resident to the bed, after the resident received the shower. Observation at this time revealed multiple red indentations on the skin on the buttocks. On 3/29/11 at 3:55 p.m. the charge nurse, Staff M came into the room and measured this resident's open area on the coccyx. The open area measured 1 cm by 1 cm with necrotic tissue in the center. The nurse stated this wound had increased in size since the last time she measured the wound one week ago and had developed the necrotic tissue in the center. The nurse stated the last time she/he saw this wound it was almost healed. The facility Pressure Ulcer Skin Assessments policy, Skin and Wound Care Protocol updated 3/2005 instructed the staff to update the aide assignment to include any interventions such as turning every two hours, keeping off affected side, etc. 2. The Minimum Data Set (MDS) assessment with a reference date of 1/14/11 assessed Resident #1 with long and short-term memory loss, severe cognitive impairment, and required extensive assistance for bed mobility, dressing and required total assistance with transfers, eating, toilet use and bathing. The MDS assessed Resident #1 as frequently incontinent of bowel and bladder. The Active [DIAGNOSES REDACTED]. This assessment noted the resident weighed 109 pounds and had a pressure ulcer. The resident received Hospice care. The Care Conference Plan of Care dated 1/25/11 addressed this resident's self-care deficit and instructed the staff to assist this resident with the assistance of two persons for transfers, due to non-ambulatory. The resident required the extensive assistance of one to two persons with bed mobility. The plan of care instructed the staff to assist this resident with frequent repositioning, and to check and change per facility protocol. The resident wears adult brief for dignity issues. The plan of care also addressed the resident's incontinence of bowel and bladder and instructed the staff to provide peri-cares in the morning, in the afternoon, and after incontinent episodes and to check and change the resident per facility protocol. The intervention directed staff to apply barrier cream after each incontinent episode and to monitor the resident's urine for signs of infection: such as foul odor or cloudy urine. The plan of care also instructed the facility to reposition the resident frequently. The plan of care identified a problem with pressure ulcers and instructed the staff to assess this resident's skin with care and noted the resident required the assistance of one to two persons for repositioning frequently. The plan of care identified this resident's incontinence and instructed the staff to toilet the resident before and after meals and as needed. The plan of care also instructed the staff to provide cleansing for the resident after incontinent episodes. When interviewed on 4/12/11 at 3:10 p.m. the Director of Nursing (DON) denied a protocol or policy for Check and Change. The DON stated her expectations were for the staff to check and change residents on a check and change schedule every two hours. A Physician's Outside Facility Note dated 1/20/11 noted the patient laid in the fetal position and had some decubiti on the pressure points of the pelvic area. A Physician's Outside Facility Note dated 9/21/10 noted the nurses were concerned about an open area that measured 0.5 cm by 0.5 cm on the right lateral hip. The Physician's recertification orders for January 2011 noted per nursing judgment apply Allevyn non-adhesive pad to the right and left hip to provide extra padding. The Care Initiatives Hospice plan of care dated 12/9/10 included skin breakdown. The interventions included to educate staff on repositioning. Observation on 3/29/11 at 7:30 a.m. revealed the resident sitting in the Geri chair. Observations revealed no repositioning or toileting assistance throughout the morning. When interviewed on 3/29/11 at 2:50 p.m. the two nursing assistants assigned to care for the resident during the day shift on 3/29/11, Staff D and Staff E, verified they provided no position changes, no pressure relief and no toileting or changing of the incontinent brief since the resident was transferred out of bed prior to 7:30 a.m. Observation on 3/29/11 at 12:30 p.m. revealed the resident seated in a Geri chair in poor body alignment with the buttocks slid toward the seat of the chair. When interviewed on 3/29/11 at 12:45 p.m. the Director of Nursing stated she would have expected the staff to lay the resident down between meals. Observation on 3/29/11 at 12:45 p.m. revealed the Director of Nursing instructed the staff to lay the resident down to check for incontinence prior to taking the resident to the dining room for the noon meal. Observation on 3/29/11 at 12:47 p.m. revealed Staff N and Staff D l (Certified Nursing Assistants) aid the resident down in bed and removed the resident ' s clothing and brief. Observation revealed this resident highly soiled with unformed feces and urine. Observation revealed feces covered the resident's skin around the penis, on and under the scrotum and on the coccyx and both buttocks. Observation also revealed a strong urine odor to the resident's pressure reducing pad in the Geri chair. The resident's disposable brief was saturated with urine and feces. After Staff D stated she/he was finished providing cleansing of the resident ' s skin, observations revealed feces remained on and under the resident's scrotum. Observation on 3/31/11 at 1:10 a.m. revealed a nurse, Staff P and a Certified Nursing Assistant, Staff O provided perineal cleansing for the resident. Observation revealed the resident incontinent of bowel and bladder. Observation revealed a new open area on the resident's coccyx. The nurse verified two open areas with red surrounding tissue. On 3/31/11 at 1:25 a.m. the Certified Nursing Assistant, Staff O and the nurse, Staff P reentered the resident ' s room. Observation revealed the resident incontinent of feces. Staff O removed the soiled brief by rolling the resident to one side and then pulling the brief out from under the resident's hip, causing shearing to the resident's skin. At this time the nurse measured this resident's open areas. The open area measured 3 cm by 2 cm. 3. Review of the clinical record for Resident #4 revealed a Nurse's Note dated 1/10/11 at 2:45 p.m. the nurse noted a 0.3 cm by 0.3 cm open area with pink base to the coccyx. The nurse wrote area cleansed and [MEDICATION NAME] Extra Thin applied per house protocol. Skin sheet initiated. Physician and family informed. A dietary report dated 2/24/11 noted no skin issues. The Nurse's Notes dated 3/27/11 at 2:30 a.m. noted an open area to the coccyx 0.3 by 0.2 cm. The nurse wrote, "Will turn every two hours side to side." The Nurse's Notes dated 3/28/11 at 2:00 p.m. noted a new physician's orders [REDACTED]. The Plan of Care dated 3/1/11 identified a problem that the resident depended upon staff for all activities of daily living due to Alzheimer ' s disease and dementia. The approaches directed staff to assist the resident with bed mobility and to use 1 staff person. The approaches directed staff to reposition frequently. The Plan of Care also addressed a problem with incontinence of bowel and bladder and instructed the staff to check and change the resident frequently and to monitor for signs of infection. The plan of care also addressed the resident at risk for skin breakdown and directed the staff to assist the resident with frequent repositioning. A History and Physical document dated 6/22/07 identified the resident with [DIAGNOSES REDACTED]. A Physician's Nursing Home Visit dated 3/17/11 assessed this resident with Alzheimer's dementia, on comfort cares and with no skin issues. A communication sent to this resident's physician dated 3/27/11 noted the resident had an open area to the coccyx. When interviewed on 3/29/11 at 12:15 p.m. a Certified Nursing Assistant, Staff D stated the resident had been up all day in his/her chair without any repositioning, perineal cleansing toileting. Staff D stated they normally left this resident up all day in the resident ' s chair. When interviewed on 3/29/11 at 12:15 p.m. a Certified Nursing Assistant, Staff E stated this resident had been up all day and received no toileting, cleansing or repositioning since they got the resident up prior to 7:30 a.m. Staff E denied any instruction as to which residents were to be assisted to bed between meals or which residents were to be repositioned. When interviewed on 3/29/11 at 12:20 p.m. the Director of Nursing stated the staff should have laid this resident down and should not have left this resident up for five hours. Observation on 3/29/11 at 1:22 p.m. revealed Staff D and Staff E took this resident from the dining room to their bedroom. Staff D and Staff E transferred the resident with the use of the mechanical lift from the chair to the bed. Staff removed the resident's clothing and the urine saturated brief. The staff described the brief as urine saturated. Observation revealed multiple red indentations of this resident's skin along both thighs and buttocks from the brief. The staff began cleansing of the buttock/anal area by wiping from the back to the front (incorrectly). The staff finished cleansing the buttock and anal areas and then prepared to apply cream to the buttock. The staff stated they were finished with the resident ' s cleansing. When interviewed at this time the staff verified they failed to cleanse this resident anterior perineal region. Observation on 3/31/11 at 1:37 a.m. revealed Staff O turned the resident onto side, unfastened the brief and then pulled the brief out from under the resident, causing a shearing force to the skin over the resident's hip. The staff then removed the urine/fecal soiled brief and then cleansed the anal/buttock skin. Observation revealed a dressing over this resident coccyx. The staff then put on a new brief. The staff then verified their failure to cleanse the resident's anterior skin. The Wound/Skin Healing Record for this resident identified a new pressure area first observed on this resident's coccyx on 3/27/11. The nurse documented the pressure ulcer measured 0.3 by 0.2 cm on 3/27/11. The staff reassessed this wound on 3/29/11 at which time identified and documented the wound a Stage 2 pressure ulcer which measured 0.3 by 0.2 cm. On 4/6/11 the staff documented the wound as a Stage 1 and measuring 2 cm by 2 cm. The staff had documented the resident ' s pressure ulcer had healed on 4/13/2011. 4. Observation on 3/29/11 at 2:10 p.m. revealed two Certified Nursing Assistants, Staff D and Staff E took Resident #13 to the bedroom in a wheelchair. The staff members stated they had last cared for this resident that morning when they assisted the resident out of bed and into the wheelchair at 8:00 a.m. The staff stated this resident had not received any repositioning, toileting or perineal cleansing since 8:00 a.m. Staff verified they left the resident sitting up in wheelchair for a little more than six hours. The staff assisted the resident from the wheelchair into the bed. The staff then removed the resident's clothing and urine soaked brief. Observation revealed red indentations in the resident's skin (posterior thighs). The staff then provided perineal cleansing of the resident's skin. Observation revealed the resident's skin on both buttocks pink to red in color. Review of this resident's clinical record revealed a Nurse's Note dated 7/26/10 at 2:30 a.m. where the nurse documented upon cares noted a 0.8 cm by 0.4 cm open area to the right gluteal crease. A Nurse's Note dated 10/25/10 at 6:30 a.m. indicated the nurse observed a 1 cm by 0.5 cm reddened area on this resident's buttocks.

Based on observation, clinical record review and staff interview, the facility failed to plan services to ensure a resident received adequate supervision from hazard in the environment with concerns identified for one of eight residents reviewed (Resident #5). The facility identified a census of 74 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #5 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had long and short-term memory loss and severe cognitive impairment and required extensive assistance for bed mobility and transfers. The resident received a scheduled pain medication. The resident was at risk for pressure ulcers and received treatment for [REDACTED]. The resident's plan of care dated 2/17/11, documented staff were to assistance the resident with bed mobility and frequent repositioning. The resident transferred via a Hoyer lift for transfers and staff were to provide treatment to the resident's right leg per physician orders. Nurse notes dated 1/16/11 at 1:30 a.m., documented a new skin abrasion below the resident's right knee that measured 7 cm (centimeters) by 2 cm. A communication sheet sent to the resident's physician on 1/26/11 noted area to the residents right lateral knee measures 4 cm by 1 cm with moderate amount of serous drainage. Nurse noted dated 2/2/11 at 10:00 a.m., noted the writer as summoned to the residents room at 5:45 a.m. by certified nursing assistant (CNA). The writer noted an abraised area possible burn to the residents right leg, slightly close to the knee measuring 5 cm by 1.5 cm. The wound was beefy red and surrounded by pink [DIAGNOSES REDACTED]. A non-pressure skin condition report dated 2/2/11, noted the resident's right lateral leg had a 5 cm by 1.5 cm open area with a depth measuring 2.5. Condition as: possible burn. An as needed medication record (a record used to show medications given on an as needed basis) revealed the resident received Tylenol with Codeine on 2/2/11 at 8:15 a.m., for right knee discomfort. The resident received the pain medication on 2/3/11 at 11:00 a.m. for right knee discomfort. A Major Injury Determination Form dated 2/3/11, noted the resident's right lateral knee had a 5 cm by 1.5 cm with a less than 0.2 cm deep open area. The resident was laying in bed on their right side, noted open area as described above. This may have been caused by heat register located to right side of resident's bed. A signed statement dated 2/15/11, documented Staff C (CNA), went to the residents room around 5:30 a.m., to check on them. When Staff C walked in they noticed the residents right leg was pressed against the heat register. Staff C noticed there was a red open area present where the residents knee was against the register. Staff C immediately turned the resident to their left side and reported the incident to the charge nurse. During interview on 3/3/11 at 11:15 a.m., Staff A (licensed practical nurse, LPN), stated Staff C summoned them to the resident's bedroom around 5:45 a.m. to report there was an abrasion to the residents right lateral knee. Staff C informed the nurse, when they entered the room the resident's right lower extremity was laying on the heat register, that was located to the right side of the bed. During interview on 3/3/11 at 10:40 a.m., Staff B (LPN), stated they were summoned to the resident's bedroom at 7:30 a.m. Staff B stated after careful observation they suspected the injury may have been caused from the heat register next to the bed. Nurse notes dated 3/2/11 at 2:00 p.m., documented a hospital wound nurse assessed the resident's wound on the right lateral knee. The wound nurse debrided the wound. The wound measured 3.9 cm by 1.2 cm by 0.1 cm deep. The wound was covered with yellow moist eschar. Observation on 3/2/11 at 2:00 p.m., revealed the resident had two wounds on the lateral aspect of the right lower extremity. The one closest to the knee was an open wound filled with eschar and the second wound was covered with a dried scab. An Internal Quality Assurance Investigation Form dated 2/2/11, noted a possible contributing factor: leg on radiator, bed too close to heat radiator.